Aged 8 11 Years Primary School

REGISTRATION FORM

(Aged 8 – 11 Years – Primary School)

Event Details

I am willing for my son/daughter/ward (name in block capitals)…………………………………………………. to attend the ‘Off Da Streets 2012’ at Worden Sports College AND/OR Leyland St Mary’s Catholic Technology College (Please delete as appropriate)

Please indicate which sessions your son/daughter/ward will be attending

Broadfield – Worden Sports College

Week Beginning

Monday

3 – 5pm

Tuesday

3 - 5pm

Wednesday

3 – 5pm

Thursday

3 – 5pm
23/07/2012
30/07/2012

Wade Hall – Leyland St Marys Catholic Technology College and The Place

Week Beginning

Monday

3- 5pm /

Tuesday

3 - 5pm

Wednesday

3 - 5pm

Thursday

3-5pm
06/08/2012
13/08/2012

Each session costs £2 (£8per person per week. Fees can be paid per session but spaces are limited)

Child/ Young Person’s Personal Details

First Name:...... Surname:......

Date of Birth:...... Age:......

Address:......

......

Postcode:...... School/College:......

Please tick which activities you would like to take part in:

Sport / Art / Drama / Dance

(Please note that Sport will include a range of different sporting activities and may take place outdoors or in the School Sports Halls, depending on the weather conditions.)

Please ensure that your son/daughter/ward is wearing appropriate clothing for the activity they are taking part in.

Parental/Guardian Contact Details

First Name:………………………………………Surname:......

Address:……………………………………………………………………………………………………………......

Postcode:...... Contact Tel No:......

Mobile No:…………………………………………Email:………………………………………......

Alternative emergency contact

First Name:……………………………...... Surname:......

Contact Tel No:……………………………………..

Address:……………………………………………………………………………………………………………......

Postcode:......

Child/Young Person’s Medical Information

Does your child suffer from any of the following conditions?

(Cross out the YES or NO which does not apply)

Asthmayes/noBronchitisyes/no

Chest Problemsyes/noDiabetesyes/no

Epilepsyyes/noFaintingyes/no

Heart Troubleyes/noMigraineyes/no

Raised Blood Pressureyes/noTuberculosisyes/no

If YES to any of the above, please provide details:

Is your child in receipt of free school meals?

YES/NO

Does your child suffer from any other condition requiring medical treatment, including medication? YES/NO If YES please give brief details:

……………………………………………………………………………………………………………

Is your child allergic or sensitive to any medication (e.g. Penicillin), insect bites or food? YES/NO If YES please give brief details:

……………………………………………………………………………………………………………

Is your child taking any form of medication on a regular basis? YES/NO

If YES, please give full details, indicating the type of medication and dosage.

……………………………………………………………………………………………………………

Please ensure that your child has adequate supplies of medication and dosage.

Does your child have any behavioural management issues or special educational needs (e.g. Dyslexia, Autism, Self Harm) which we need to be aware of YES/NO

If YES, please give details

……………………………………………………………………………………………………………

Are they receiving treatmentYES/NO

If yes please give details of which agency/ organisation is providing treatment: ……………...

……………………………………………………………………………………………………………

Agency/Organisation Tel. No.:…………………………......

Family Doctor (Name and address)………………………………………………………………..

……………………………………………………………………………………………………………

Family Doctor Tel. No:…………………………......

I agree/disagree(please delete) to allowing my son/daughter to receive medication as instructed and any emergency dental, medical or surgical treatment including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

Insurance Cover

I understand that the event is insured in respect of legal liabilities (third party liability) but that my child has no personal accident cover unless I have been specifically advised of this in writing by the organiser of the visit. I also understand that any extension of insurance cover is my responsibility unless advised differently by the Leyland Project.

Travel

I understand that if required my child will be transported to and from any incorporated organised trip by staff or volunteers of the Leyland Project and that any driver will have the appropriate qualifications and/or insurance needed to do so (e.g. MIDAS).

Behaviour

I acknowledge the need for my child to behave responsibly during the sessions listening to and taking instructions from session leaders and workers.

Media i.e. photos/ video

We would like to take photographs of the young people during the project and on trips and outings. We might want to use these images for promotional purposes, either in our printed publications, or on our website, or both. These images may also be submitted to external funders such as Progress Housing Group, Lancashire Young People’s Service and South Ribble Partnership.

To comply with the Data Protection Act 1998, we need your permission before we take any pictures of you or your child/ward. If photographs of groups are organised, and individuals could be easily identified, project workers must find out whether you want yourself or your child/ward to be included.

Please answer the questions below.

Please circle your answer
I am happy for my photograph/my child’s photograph to be taken / Yes / No
I am happy for my image/my child’s image to be used in printed publications / Yes / No
I am happy for my image/my child’s image to be used on The Leyland Project’s website
I am happy for my image/my child’s image to be submitted and used by external funders. / Yes / No
Yes/No

Declaration

I have read the attached information provided about the proposed activity and the insurance arrangements.

I consent to my child/ward taking part in the activities described and having read the information sheet, declares my child to be in good health and physically able to participate in all the activities mentioned.

I understand how my consent is to be used if my child/ward is in need of receiving emergency medial treatment.

I am aware of how my child/ward will be transported to and from the visit.

I have noted where and when the activity is taking place and I understand that I am responsible for my child/ward getting home safely from that place.

I am aware of the levels of insurance cover.

I understand that any photos or videos taken of my child/ward will be used appropriately.

I will ensure that any change in the circumstances (e.g. recent medication or injury) which will affect my child’s/ward’s participation in the visit will be notified to the Leyland Project prior to my child attending the organised activities.

I ACCEPT THAT THERE IS AN INHERENT RISK OF INJURY IN PARTICIPATION OF ADVENTUROUS OUTDOOR ACTIVITIES. RISK CAN BE REDUCED TO ACCEPTABLE LEVELS BY IMPLEMENTING APPROPRIATE RISK ASSESSMENTS. COPIES OF WRITTEN RISK ASSESSMENTS ARE AVAILABLE ON REQUEST FROM THE LEYLAND PROJECT.

Signature of Parent/Carer (Parental/Carer consent required for children aged 17 and under)

Name in block letters …………………………………………………………

Signature:...... Date:…………………..

In the case of the applicant being over 18 years of age, the following must be read and signed:

I declare the above information is correct and that the person in charge has my permission to authorise medical treatment in an emergency. I consent to medical treatment if deemed necessary by the attending authority present and the use of anaesthetics being given in the case of an emergency.

Signed:………………………………………………………………………Date:……………………

THE LEYLAND PROJECT IS REGISTERED WITH THE CHARITIES COMMISSION REGISTERED NO 1105380

PLEASE RETURN COMPLETED FORMS EITHER BY EMAIL TO

ALTERNATIVELY BY POST TO

‘Off da Streets’, The Leyland Project, ‘The Place‘ Community Centre, 73 Royal Avenue, Leyland,

PR25 1BX

PLEASE RETURN THE FORM NO LATER THAN FRIDAY JULY 20th 2012

‘Off da Streets’ is supported by