Cippenham Baptist Youth

Discoverers/Adventurers

and Back Chat 11 Elmshott Lane, Cippenham

WEB

Part 1 (General Information)

To be completed by the parent/guardian

Name of person applying for membership:
Date of Birth: / Age:
Address:
Postcode:
Tel Number(s) of parent/Guardian:
Name of emergency contact (not parent/guardian):
Emergency contact number
Email Address

Part 2 (Medical Information)

Please confirm if your son/daughter has any illnesses or disabilities that we should be made aware of. Please confirm any medication required and detail any advice you feel we should know about your son/daughters illness.
In rare cases we may have need to administer simple first aid, such as plasters/cold compress. Do you give permission for simple first aid to be administered? / YES / NO

Part 3 (Photography, filming & Internet)

Photography/Filming

We believe it is good to record our trips and activities so we often film or take photos of the group. These photos are used for the sole purpose of advertising and promoting the youth group and looking back in future years. We will not take any photos of your son/daughter without your permission
Do you give consent for photos for your son/daughter to be taken for the sole purpose of advertising and promoting the youth club? / YES / NO

Internet

Cippenham Baptist Youth are part of the church web site at we would like to put both some of the photos taken and filming done on the website solely for the purposes of promoting the youth club.
Do you give consent for taking photos/filming of your son/daughter to be done for the sole purpose of advertising and promoting the youth club? / YES / NO

Part 4 (Declaration by Parent/Guardian)

I can confirm that the information I have provided on this application form is correct as at the time of completion. I can confirm that I am the legal parent/guardian of the member. I have read the enclosed information sheet and I am happy for my son/daughter to apply to become a member of Cippeham Baptist Youth. I understand that this only includes all Cippenham Baptist Youth activities held at the church building and that separate permission will be required for any trips away from the building.

Signed: / Name:
Relationship to the applying member: / Dated: