Registration and Consent: Potting Shed Youth

To be completed for each child who wishes to attend Potting Shed Youth activities, by their parent/carer.
(The information requested on this form can be completed by a carer, but only those with parental responsibility can sign the consent.)

Young person's full name

Date of birth

YYYY

Full name of parent / guardian

First Name

Last Name

Home address

[I'd pop here why we're asking?]

Phone

Required in case of any emergencies

(###)

###

####

Tick "Sign up for news and updates" if you would like to receive The Potting Shed weekly email. Leave the box unticked if you only want us to contact you as necessary about Rooted Youth.

Does your child have any food allergies?

(If yes, please specify:)

Does your child have any medical conditions?

(If yes, please specify:)

Is your child on any medication?

(If yes, please specify:)

Does your child have any special needs?

(If yes, please specify:)

Is there anything else you would like us to know about your child?

Contact name and number for an alternative adult in case of emergencies

Someone contactable during the group or activity time. Please let us know their relationship to you/your child, e.g. grandparent.

Declaration

(Wednesdays) I give permission for the above named young person to attend and take part in the Potting Shed Rooted Youth activities.

(Sundays) I give permission for the above named to walk to and from Norwell vicarage from the village hall (250m) and participate in outdoor games and activities (always under the supervision of an adult).

I give permission for the above named young person to travel in a leader’s private car, when necessary and by prior arrangement.

I give permission for the above named young person’s image to be photographed/videoed and used for The Potting Shed displays, website and social media (unnamed).

I understand that while those working with my child will take all reasonable care, they cannot necessarily be held responsible for any loss, damage or injury suffered by the named child during, or as a result of, the activity.

All data submitted will be treated confidentially.
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VENUE:

Norwell Vicarage
The Vicarage postcode is NG23 6JT but this may also take you to the Old Vicarage so instead use
Main St, Norwell, Newark NG23 6JN
or what3words:
https://w3w.co/tracking.capers.continued