T:BUC TEch & ADventure SUMMER CAMP

Child / Young Person's Full Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth *

MM

DD

YYYY

Parent / Guardian Name *

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

If available at this centre / project, do you give consent for child/young person to have access to the ICT Facilities and Internet? *

Yes

No

Some centres / projects also provide group work through online video conferencing (ZOOM), do you give consent for your child / young person’s participation? *

Yes

No

May we use your young person / child’s image in our printed promotional publications? *

Yes

No

May we use your young person / child’s image in the local press? *

Yes

No

May we use your young person / child’s image on our website / Social Media? *

Yes

No

May we record your young person / child’s image on our promotional videos? *

Option 1

Option 2

I agree and understand that if my child leaves the premises early, the youth club and or WheelWorks will not be responsible for the young person once they have left the premises. *

Yes

No

Do you grant permission for WheelWorks to share your child / young person’s details with PHA Test, Trace, Protect, if requested by the service *

Yes

No

*

By agreeing to this form: — I confirm that I have received and read the Parent / Guardian Information Pack — I will inform the Youth Worker in Charge of any changes to my child’s health, medication or needs which could affect their participation in activities — I will inform the Youth Worker in Charge of any changes in address or relevant numbers given above. — I will discuss with my child acceptable behavior and insist they follow the anti-bullying policy of the club and all other relevant policies within

Agree

Full Name *

First Name

Last Name