Young Person's Permissions Form

Please complete this form to share with us any health information we need to be aware of to keep you / your young person safe, and to ensure we understand what you do and don’t consent to:

Your / Young Person's Contact Details

First Name

Has your / the young person's address , telephone number or email changed since the Initial Referral?

Yes

Last Name

New address or contact details:

Aged over 18?

Yes

Parent / Carer Details

Parent / Carer Name

Telephone No.*

Address

Email address

Postcode

Keeping safe

Any Medical conditions we need to be aware of during activities?

Yes

Please provide details

Any Prescribed medication?

Yes

Please provide details

Any allergies or special dietary requirements?

Yes

Please provide details

Emergency Contacts

What is the name of your / the young person's emergency contact?

Relationship to you / young person?

Have you already provided contact details for your emergency contact on this form?

Yes

Emergency Contact's Tel No.*

Emergency Contact's Email address

Emergency Contact's address

Registered GP / Practice

GP / Practice telephone number

Do you, the young person, consent to first aid or urgent medical treatment being given during the activity?

Yes

Do you, the parent/carer consent to first aid or urgent medical treatment being given during the activity?

Yes

Parent / Carer Permissions

We will use the contact details you have provided above to contact you about your child's programme. In addition:

Can we contact you, the parent / carer, about other US programmes which we think may be of interest to your child?

Yes

Can we add you, the parent / carer to our mailing list to keep them updated about US?

Yes

Do you consent to us using photographs or video of your child in relation to this programme?

Yes

Do you consent to us using photographs or video of your child for general marketing and promotion of US?

Yes

Young Person's Permissions

We will use the contact details you have provided above to contact you about your programme. In addition:

Can we contact you about other US programmes which we think may be of interest to you?

Yes

Can we add you to our mailing list to keep you updated about US?

Yes

Do you consent to us using photographs or video of you in relation to your programme?

Yes

Do you consent to us using photographs or video of you for general marketing and promotion of US?

Yes

Agreements

US values your privacy and is committed to protecting your data. This information will be held securely on computer and within manual files. As a data processor we are registered with the ICO and committed to meeting the requirements of GDPR.The personal information we collect about you will mainly be used by our staff (and volunteers) at US so that they can deliver our activities and provide the best support to you. We will never sell or share your personal information with organisations so that they can contact you for any marketing activities. US may share your information with our trusted partners and suppliers who work with us or on our behalf to deliver our services, with other groups or agencies for continuation of or new support for you, and with bodies who have provided funding for our work with you and other young people. We may disclose your information if required to do so by law (for example, to comply with applicable laws, regulations and codes of practice or in response to a valid request from a competent authority)

- I acknowledge and consent to the above personal information handling and sharing

- I give my consent for US to use the information I have provided to offer information, advice and support.

- I wish to take part in activities identified and agreed between US and me.

Agreements

US values your privacy and is committed to protecting your data. This information will be held securely on computer and within manual files. As a data processor we are registered with the ICO and committed to meeting the requirements of GDPR.The personal information we collect about you and your child will mainly be used by our staff (and volunteers) at US so that they can deliver our activities and provide the best support to your child. We will never sell or share your personal information with organisations so that they can contact you for any marketing activities. US may share your information with our trusted partners and suppliers who work with us or on our behalf to deliver our services, with other groups or agencies for continuation of or new support for your child, and with bodies who have provided funding for our work with your child and other young people. We may disclose your information if required to do so by law (for example, to comply with applicable laws, regulations and codes of practice or in response to a valid request from a competent authority)

- I acknowledge and consent to the above personal information handling and sharing

- I give my consent for US to use the information I have provided to offer information, advice and support.

- I give consent for my child to take part in activities identified and agreed between US, them and me.

Name of person completing this form

I have completed this form about myself

Yes

I am over 18

Yes

Signature of Young Person

I give my consent for this information to be shared with US.

Please type your name here

16/01/2025

Signature

Name of person completing this form

Relationship to young person

The young person is Under 18

Yes

Signature of Parent / Carer

I give my consent for this information to be shared with US.

Please type your name here

16/01/2025

This field should be left blank

Young Person’s Permissions Form

Your / Young Person's Contact Details

Parent / Carer Details

Keeping safe

Emergency Contacts

Parent / Carer Permissions

Young Person's Permissions

Agreements

Agreements

Signature

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