Parental Consent

Name of member:

Date of birth:

Age:

Home address

Postcode

Phone number

Name of emergency contact

Relationship to the member (e.g. mother, brother, neighbour)

Home address

Home telephone number

Work telephone number

Mobile number

Name of doctor

Doctor’s address

Doctor’s telephone number

Please provide details of any pre-existing medical conditions that may affect participation at the club

Please detail any allergies, including allergies to medication

Have you received a tetanus injection in the last five years?

yes no

Can the participant swim at least 25 metres?

Yes No

Please state any other information you feel is relevant

I consent to the named young person joining The Gaff and participating in all core activities of the youth club. I understand that I will be asked for specific consent for all additional activities, events or residentials

yes no

I consent to the club member receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I understand the extent and limitations of the insurance cover provided

yes no

Use of Photographs, Film or Video Recordings During your participation in the club/group, photographs and film clips may be taken. We would like your permission to use the photographs in the following ways: in ORGANISATION publications, website and exhibitions (including DVD and slide shows); shown at events to generally promote the work of The Gaff; used by trusted partners and funders such as the Moray Council. You should be aware that The Gaff website is viewed by a world-wide audience and The Gaff cannot prevent pictures being copied and used by others. I consent to the named young person’s image (photo/video) being used in the ways described above

yes no

🖊️ Your Digital Signature (Required)

Draw your signature above

Signature is required

Legal guardian name

Relationship to participant:

Guardian Email Address (this is where a copy of the form will be sent for your records)

Name of member:

Date of birth:

Age:

Home address

Postcode

Phone number

Name of emergency contact

Relationship to the member (e.g. mother, brother, neighbour)

Home address

Home telephone number

Work telephone number

Mobile number

Name of doctor

Doctor’s address

Doctor’s telephone number

Please provide details of any pre-existing medical conditions that may affect participation at the club

Please detail any allergies, including allergies to medication

Have you received a tetanus injection in the last five years?

yes no

Can the participant swim at least 25 metres?

Yes No

Please state any other information you feel is relevant

yes no

🖊️ Your Digital Signature (Required)

Draw your signature above

Signature is required

Legal name

Email Address (this is where a copy of the form will be sent for your records)

what’s on

volunteer

charity

gallery

about us