Parent / Carer Agreement Form

13 August 2022

This information will be used by South Bristol Youth to enable us to run our activities. If you have any questions, please do not hesitate to contact South Bristol Youth using the contact details provided on our website.

Child's Information

Please tick this box if you know that your child has previously been involved in an SBY programme.

First Name*

Preferred Name

Last Name*

School Name*

Year Group* in the form Yxx

Date of Birth* in the form DD/MM/YYYY

Child’s Mobile Number

Home Address: Street*

City*

Postcode*

Medical Information

Please tell us below if your child has any medical conditions we need to be aware of, e.g. asthma, allergies. Please say whether they need to carry an inhaler or adrenaline auto-injector.

If your child does not have any medical conditions, please confirm this by writing ‘None’.

Other Information

Is there any other information we need to know that will help us support your child as they take part in the programme?

PARER OR CARER CONTACT INFORMATION

Whilst your child is working with us we will be contacting you with additional information about the programme. We may also need to use this information in the event of an emergency. Please provide us with the following information:

Parent/Carer Name*

Parent/Carer Email Address

Parent/Carer Mobile Number*

Parent/Carer Landline Number

CONSENT AND SUBMISSION

I give permission for my child to appear in photographs and videos taken by South Bristol Youth, Future Quest, UWE, University of Bristol, participating schools and colleges and their approved suppliers and staff. These images may be used for publicity, in printed material, and on the websites of those organisations, and may include use on their social media feeds including, but not limited to, Instagram, Facebook, Twitter and YouTube.

Yes, I accept No, I do not accept

Signature of the Parent/Carer*
(please type in the box)
Dated