This form is to be completed in full by a parent or carer only, and covers all regular attendance at any of our church groups and events for youth from September 2022 to August 2023.
Please name the School and Year the young person is currently in.


Details of young person:

Young person's full name:
Preferred 'known by' name (if different to above):
Sex: Male
Please select which sessions you plan to attend, either or both:

Friday (7.30-9.15pm
Sunday (9:30-10:30am)

Home telephone:
Do you give permission for your child to receive emails and text messages from staff or volunteers from church?
(All methods of communication are in compliance with our Safe From Harm Policy. All emails go to both carer/parent and youth)
Mobile number of young person:
Email address of young person: We will always email both parent & youth.
Date of birth:
School (from Sept 2022):
School year (from Sept 2022) :
Notifiable medical conditions/Additional Needs:
Include allergies, details of medication and any medical details we need to know, e.g. Epilepsy, ADHD, Asthma etc OR Additional Needs that require support.

Parent / carer contact details:

Parent's full name:
Mobile number:
Email address:
Relationship to young person:

Emergency contact details:

Parent / carer details given above will be used as the first emergency contact, however please supply a second contact for emergencies
Second Emergency Contact Name:
Phone number:
Relationship to young person:

Media and electronic communication:

The church may also take photographs / video at groups which may include your child. They may be used to publicise further events or in church publications.  Any pictures or video taken will be used sensitively and in compliance with our Safe From Harm Policy, which is available to read here.
Do you give permission for your child to appear in these photographs / videos and for these to be used by the church?
Do you also give permission for the photographs / videos to be used on the church website and social media sites?


I give permission for the young person named to take part in the normal activities of the youth groups. I understand that separate permission will be sought for certain activities, including off site trips operating outside the usual group times.

I understand that while involved he / she will be under the control and care of the group leader, and / or other adults approved by the church leadership and that, while the staff in charge of the group will take all reasonable care of the children, they cannot necessarily be held responsible for any loss, damage or injury suffered by him / her during or as a result of, the activity.

I confirm that by clicking 'Send' I am submitting full and accurate information, that I am the parent / carer of the young person named, and that I give permission for the young person named to take part in the normal activities of the youth groups.
In an emergency and / or if I am not contactable, I am willing for him / her to receive necessary hospital or dental treatment including an anaesthetic.