Young Person Registration Form

Club/Session

Previously Registered?

Yes No

Full Name

Date Of Birth

Address

Post Code

Home Tel No

Mobile No

Gender

Parent/Guardian

This information will be used for emergency contact

Full Name

Address

Post Code

Home Tel No

Mobile No

Medical Info

Any Medical Issues:

Official Diagnosis

Consent and confirmation of Parent/Guardian:

I accept responsibility for my son/daughter’s behaviour and will explain his/her responsibilities to him/her before they attend. Youth Workers supervising sessions cannot be held responsible for young persons -

(1) until they have arrived at the centre and reported in

(2) upon leaving the centre, whether or not at the conclusion of a session.

Young person’s leaving before the conclusion of a session must first advise supervising staff before doing so.

By signing this form, you confirm that you have received a copy of Corbridge Youth Initiative Data Privacy Statement and you consent to the executive committee holding and processing your personal data and that of the child referred to above in accordance with the provisions of that Data Privacy Statement.

Yes No

We occasionally use photos or videos from Youth Club’s activities our young people have been part of. These images are sometimes used to publicise our work in Newsletters, local press, posters, reports, displays and presentations. Are you happy for your child’s photo to be taken and used by Corbridge Youth Initiative?

Yes No

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