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Cart
0
Get support and advice
Get Support
Fruit and Veg For Families
Christmas Toys
Zebras Youth Club
Family Special Events
Autism Support
Get involved
Volunteer
Company-to-Community Initiative
Mission
Work with us
Zebras Recruitment
Our Team
Browse our charity shop
Donate
Consent Form
Please complete the form below
Type of activity/what the child or young person will be doing
*
1. Child or young person’s details
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
(###)
###
####
Date of birth
MM
DD
YYYY
2. Parent or carer’s details
Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
Date of birth
MM
DD
YYYY
3. If there’s an emergency, please contact:
Name
*
First Name
Last Name
Phone
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
4. Child’s medical details
GP
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
5. Do we need to provide any extra help, for example because of a disability, or are there any activities that your child cannot participate in?
*
6. Do we need to know about any medical conditions or allergies? (If yes, please provide details of the condition(s) and any medication needed).
*
7. Is there anything else you think we should know?
*
Information for parents and carers Zebras Children and Adults Charity aims to provide a safe and enjoyable experience for every child or young person. To help us do this, please note the following important information. • All questions on the consent form must be completed and signed by the parent or carer before any child takes part. • Parents and carers must ensure they notify us of any changes to the information given on the form. • Parents and carers must make arrangements for children to be brought to and from the activity safely and on time. If a parent or carer is not able to collect their child, they need to let us know in advance who will be doing so. • We cannot take responsibility for any damaged clothing and/or personal items during the activity. • Parents and carers should ensure children have sufficient water, food, clothing, sun lotion and medication (where appropriate) for the duration of the activity.
I agree to (please tick):
My child taking part in the stated activity
Zebras Children and Adults Charity keeping a record of this form for health and safety reasons
Any medical treatment that my child may need to be given in an emergency
My child being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity.
Zebras Children and Adults Charity will take all steps to ensure these images are used solely for the purposes for which they are intended. Note: if consent is not given, Zebras Children and Adults Charity will not use any images taken during the activity that contain the child/young person. I understand that my child needs to follow the behaviour code and any safety rules so that Zebras Children and Adults Charity can keep them and other children safe.
Print name
*
Date
MM
DD
YYYY
Child or young person I agree to (please tick):
Taking part in the activity
Talk to Harriet Piercy or youth leader if I am not comfortable at any time during the activity so they can help me or arrange for me to do something else
Zebras Children and Adults Charity keeping a record of this form, so they have the information they need to keep me safe during the activity
Receiving any emergency medical treatment that I may need
Being filmed or photographed during the activity.
Print name
*
Date
MM
DD
YYYY
I understand that the photographs or film might be used to tell other people about what Zebras Children and Adults Charity does. Note: If I don’t agree to this, Zebras Children and Adults Charity will not use any images of me. I understand that enjoying the activity and being safe means, I need to follow the behaviour code and safety rules where possible.
Thank you!
