YMCA TG Woolwich Youth Registration Form

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12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Person completing this form

This form should be completed by a Parent/Carer if young person is under 16. (Under certain circumstances Gillick competent youth aged 13-15 may self-consent - seek advice of project manager)

Young Person / Child details

First name

Last name

Date of birth

Gender

Ethnicity

Religion

Young Person / Child Contact information

Address line 1

House/flat number & street

Town/City

Post code

Phone number

Status

School/College attended

Other School/College

How did you find out about YMCA Woolwich Youth?

Other (please specify)

Medical/Dietary Information

Any known medical conditions?

i.e.asthma, diabetes, heart condition, back pain etc.

Medical condition(s) details

Any known allergies?

Food allergies and any other allergies e.g. bee sting

Allergies details

The level of reaction and actions required i.e. EpiPen

Takes regular medication?

Medication details

Please include name, dosage and frequency

Any special need or disability?

Special needs & disability

Please select from list and add details below

Level of support

Please summarise the level of support needed to suit additional needs

Any other additional needs?

In addition to what has already been stated

Additional needs

Please provide details of any additional needs diagnosed or not (i.e. anxiety, struggles with reading/writing, autism, ADHD, struggles to concentrate)

Any dietary requirements?

Dietary requirements

Any other concerns

Any other emotional, social, educational, health concerns or support needs for you/your child or family?

Parent/Carer & Emergency Contact Details

Parent/Carer 1

Parent/Carer Name

Relationship to young person

Same address as young person?

YesNo

Address & post code

If different from address of young person

Mobile

Home phone

Do they have parental responsibility?

Are they an Emergency Contact?

At least 1 emergency contact must be provided. If this parent/carer is not an emergency contact, a new section will appear where you must enter a second parent/carer who is.

Would you like to add details for a second Parent/Carer?

Parent/Carer 2

Parent/Carer Name

Relationship to young person

Same address as young person?

YesNo

Address & post code

If different from address of young person

Mobile

Home phone

Do they have parental responsibility?

Are they an Emergency Contact?

Behaviour Agreement

I understand that I/my child should behave respectfully at all times towards the staff at the YMCA club, the other young people present, the equipment and building. I understand that I/my child should follow any instruction given by staff to ensure the smooth running of club and the safety of all. If I/My child behaves disrespectfully, or doesn’t do what is asked of them by staff I understand that I/they could be asked to leave the club / session.

For those under 16 (accept 13-15s with self-consent), I understand that if my child is asked to leave the session I will be called to be informed of the situation and I agree to cooperate to ensure they leave the session.

It is our general policy to welcome all young people back to club for the next session, even if they were asked to leave previously, on the understanding that they should be respectful to staff, each other, the equipment and the building.

Please tick if you agree

Yes

First name no special characters

Last name no special characters

Data Protection & Privacy

For information on how YMCA TGG use and store your data please visit https://ymcatg.org/privacy-and-cookies, or contact us on 01708 766211 or dpo@ymcatg.org.

We ask that you keep us informed of any changes to the details contained in this registration form. Periodically we may ask you to confirm your details for our records.

Consent

I agree that my/my child’s images may be stored and used by YMCA Thames Gateway Group and third party organisations to promote YMCA through various printed and digital communications, and my data may only be used for legitimate promotional purposes.
I understand that the YMCA Thames Gateway Group will retain copyright, can edit images at its sole discretion, and I will not be paid a fee in respect of any use made of images.
I understand that the images will enter in the public domain and therefore could potentially be reproduced by anyone in the world outside the control of YMCA Thames Gateway Group

I provide consent for my/my child’s school/college to be contacted

This is to provide positive feedback and communicate to provide the best support for you.

In the event of an accident, I give my full consent for a trained member of staff to apply first aid to myself/my child

In case of emergency, I give permission for the staff to seek necessary emergency medical advice or treatment

Please note that we will contact the emergency contact immediately

I understand that this is a drop-in session and attendees are permitted to leave the session at any time

I give permission for myself/my child to be transported in a minibus with suitable seating and seatbelts

I confirm that the information given in this form is accurate, true and complete

Yes

Name

Relationship to young person

Date

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