The Hangleton & Knoll Project

Youth Activity Membership & Registration FormForms need to be returned to The Youth Team Office at St Richard’s Community Centre, Egmont Road or Hangleton Community Centre, Harmsworth Crescent.If you have any questions or need more information, please ring Michelle on 706469.

Activities _________________________ Date _____/________/_________________________________ Date_____/________/_________________________________ Date_____/________/_________________________________ Date_____/________/________

Participant Name _________________________________________________

Date of birth Gender Male / Female

Parent/Guardian Name Relationship to child

Address

E-mail address

___________________________________________________

___________________________________________________

________________________________________ If you do not want to receive information about local youth work taking place then please tick the box ( ).

Postcode ___________________________________________________

Home Telephone Mobile

Emergency Contact Name

Relationship to child

Emergency Contact Numbers:

__________________________________________________

IMPORTANT: Does your child have any medical conditions? Yes No (e.g. asthma, diabetes, epilepsy, allergies)

If yes please give details__________________________________________________________

If your child takes any medication please give details: _________________________________

Do you consider your child to have a disability? Yes No Prefer not to say

If yes please state: ________________________________________________________

Do you consent for your child to go home unaccompanied? Yes ( ) No ( )

Yes No I consent to any emergency medical treatment necessary during therunning of the activity. I authorise the staff to sign any written form ofconsent required by the hospital authorities if the delay of my signatureis considered by the doctor to endanger my child’s health and safety.

Yes No Signature of Parent/Guardian _________________________

Please take note of the following conditions:

Our equal opportunities policy ensures of equality of access, experience and quality to all using our services. We consider language, behaviour or action that is designed to be offensive or create discrimination to any user of the service or member of staff, unacceptable and will not be tolerated.It is crucial that all participants are able to enjoy the activities provided. Please understand that it is important for you safety and of others, that any rules and instructions given by staff are followed.

I have read and understood the above Equal Opportunities StatementYES (please tick)

Aspire Database

The Hangleton & Knoll Project records information on a joint Brighton & Hove City Council/East Sussex County Council database called Aspire. Information that we will record on this secure database consists of the names of those who attend activity sessions and details of what took place at the session. Only authorised professionals are able to access the database. If you DO NOT want your attendance or any other information about you recorded, please tick the box below.

Asian or Asian British

Asian BritishAsian - IndianAsian - PakistaniAsian - BangladeshiAny other Asian backgroundPlease specify ……………………

Black or Black British

Black BritishBlack CaribbeanBlack AfricanAny other Black background

Please specify ……………………

Chinese or other South-East Asian

Chinese

Other

Please specify ……………Dual Ethnicity

White & Black CaribbeanWhite & Black AfricanWhite & AsianAny other backgroundsPlease specify ……………………

White

White BritishWhite IrishAny other White background

Please specify ……………………

Other

Please specify ………………..

Prefer not to say

I declare that the information I have provided is complete and accurate

Signature of Participant ____________________________Date Form Signed: ___________

Signature of Parent/Guardian _____________________ __Date Form Signed: ___________

Please note: To assist in the production of future promotional material Hangleton & Knoll Project may photograph

activities organised by the Project. If you have any objections of yourself or your child (if applicable) being pictured for these purposes, please tick this box. Please note that in some instances the photographs may be distributed to the wider media and also used on theHangleton & Knoll Project Website

To assist with promotion of new and existing activities, we may wish to contact you regarding future activities at the address above. If you have any objections to this please tick this box