Holiday Bible Club Consent form

Parental Consent Form – Follow HBC 2016

 SECTION A:  Details for the child

First name:_______________________

Last Name________________________

Date of Birth _____________________

Address:___________________________

__________________________________

Town: ____________________________

County:___________________________

Postcode:__________________________

Tel number: ________________________

Email address _____________________

Mobile Number ____________________

School  __________________________

 

SECTION B: Medical and Dietary Information

GP’s Name _________________________

GP’s Address __________________________________

__________________________________

__________________________________

GP’s Tel number (______) _____________

 

Relevant Medical details (attach on a separate sheet  if necessary)

__________________________________

 

Has your daughter/son been vaccinated against Tetanus?               YES/NO

In an emergency, if you cannot be contacted, are you willing for your son/daughter to receive necessary hospital treatment including an anaesthetic?                                     YES/NO

Do you consent for your child to be transported by ambulance with a member of church staff?               YES/NO

Dietary requirements:___________

______________________________

National health number

________________________________

 

 

SECTION C – Emergency contact information

Name _____________________________

Address ___________________________

 

Tel number:___________________________

Name _____________________________

Address ___________________________

 

Tel number:___________________________

SECTION D – Declaration and consent  I confirm that I have parental responsibility for the above named person.  I have read and understood the enclosed information regarding this activity and consent to him/her participating in all the activities(see over the page).  I consent to photographs and video footage being taken for the purposes of (please circle): Group              Display boards                        Website           Advertising      All        None To the best of my knowledge all the information contained on this form is correct and up to date. Signed: ___________________________     Print name: _______________________ Date:_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Activities