Do you have a religion, belief or cultural custom that it would be helpful for us to know about?
What form of communication, if any, does the young person prefer for the youth service to make contact with them? (Please tick)
o Home telephone o Mobile Phone o Text message
o Letter to home address o E-mail o No communication
Photographic / Video Permission
Whilst young people are taking part in activities organized by our service we occasionally like to record an event or activity by taking photographs or using a video camera. The images may be used for reports, displays etc or just as memories for the young people. We are aware of the sensitivity surrounding this issue and therefore will not photograph / video any young person without the consent of their parent / carer.
If you agree for your son / daughter / ward to be photographed / videotaped during the normal course of an activity please complete the form below.
I am the parent / legal guardian of the child named overleaf and I give permission for my child to be photographed or videotaped whilst in the care of the organization named overleaf
o (Please tick)
For child protection reasons, children’s names will not be given in any publication. However if you are happy for their full name to appear in a News Paper article please tick this box
o (Please tick)
Young person’s declaration
I agree to ground rules set by Plymouth City Council Youth Services which inform young people what is acceptable behaviour within Youth Centres & Youth Service Activities. I understand that there will be consequences to participating with the youth service if these are broken.
Name (please print)………………………………………………………………..
Signed……………………………………………………………………… Date……../………../……
Parents / Guardians / Carers (if under 18) Young person can complete if over 18 years of age
I confirm that the information on this form is accurate and I understand that it is my responsibility to advise staff of any changes.
I give permission for the named young person overleaf to attend Youth Centres and services provided by Plymouth City Council Youth Service and also that they may:
· Receive any necessary medical treatment in my absence
· Have their image recorded as part of youth work activities
· Use computers and the internet (if facilities available) as long as they abide by appropriate guidance
I understand that this information will be held on record, and that this information will be used only by the Youth Service
Name……………………………………………………………………………………..
Signed ……………………………………………………………………………………
Relationship to young person (if young person under 18)…………………Date……/……/……
For office use only
Date of QES entry ………../…………../………
Update by (workers name) ………………………………………………
QES Reference Number …………………………………………………
2