EMERGENCY CONTACT DETAILSYoung Person’s Name* First Last Date of birth*ADDRESS* Street Address Town/City County Postal Code Parents’ / Guardians’ Name* First Last Parents’ / Guardians’ Address (if different) Street Address Town/City County Postal Code Daytime Phone*Evening PhoneMobile Phone (if different)Email* I consent to my contact details being stored electronically and on paper for the purpose of my child's involvement with King's Church High Wycombe.* Yes NoWe will hold your information for 1 year after the event. You can view our Data Protection Policy or request to be removed from our database at any time by emailing office@kchw.co.uk or ringing 01494 459 901.I consent to being contacted by King's Church High Wycombe in regards to Youthwork (Please tick all that apply.)* Post Email Mobile Phone Home PhoneYou can change your contact preferences at any time by emailing office@kchw.co.uk or ringing 01494 459 901.MEDICAL DETAILSDoctors' Surgery*Doctors' Surgery Address*Date of most recent anti-tetanus vaccination?1. Does your young person have any SPECIAL DIETARY requirements?*NoYesPlease give details below2. Does your young person have any allergies?*NoYesPlease give details below3. Details of any illness / disability...4. Details of any medication required during the camp (including inhalers).Please make sure your young person brings ALL necessary medicines in their original packaging, making sure they are NAMED clearly and with clear instructions as to the dosage and frequency required.5. Please also mention any concerns about behaviour issues / home sickness etc or any other information which may be helpful, to enable the leaders to give the best care for your young person.EMERGENCY CONSENTPlease tick the boxes below, and sign and date the bottom of this page:1. I give permission for my young person to be given paracetamol if they are suffering from a headache or other minor ailment.*YesNoWhat should we give them instead?2. In the unlikely event of illness or accident, I give permission for my child to receive any medical treatment that a First Aider deems necessary.*YesNo3. In an emergency and/or if I am not contactable, I am willing for my child to receive doctor, hospital or dental treatment including an anaesthetic.*YesNoI give permission for the young person named on this form to take part in the planned activities while away. I understand that, while involved, he/she will be under the control and care of the group leader and/or other approved adults and that, while the leaders of the group will take all reasonable care, they cannot necessarily be held responsible for any loss, damage or injury suffered by my child during the time away.*YesNoI consent to my child's medical and emergency information being stored electronically and on paper for the purpose of my child safely attending events with King's Youth.* Yes NoIF YOUR CHILD IS AGED 13 & OVER, WE WILL ALSO BE ASKING THEM FOR THEIR PERMISSION TO HOLD & PROCESS THEIR PERSONAL AND MEDICAL DETAILS. We ask for this information at least once a year in order to ensure it is current and relevent, and automatically delete the information after that. You can request that the information is deleted at any time by emailing office@kchw.co.uk or ringing 01494 459 901, however for your child's safety we will not be able to take them to an event without current information provided and stored.PHOTO AND VIDEO CONSENTWe may take photos or record videos during the course of our time away which may include your young person. These images may appear on a notice board at the church, in a presentation to the church, on the King’s Youth website or in King's Youth Social Media accounts. IF YOUR YOUNG PERSON IS AGED 13 & OVER THEN WE WILL ALSO BE ASKING THEM FOR THEIR PERMISSION TO USE THEIR IMAGE.1. May we use your child’s image (still or video) within the church (printed, e.g. banner)?* Yes No2. May we use your child's image (still or video) on the King's Youth Social Media accounts?* Yes No3. May we use your child's image (still or video) on the King's Church website, YouTube channel or Social Media accounts?* Yes NoNotes: This form is valid from the date of completion until your child is aged 13 & over. Your consent will automatically expire after this time; We will not re-use any images after this time; We will not include details or full names (which means first name and surname) of any person in an image on website, or in printed publications, without good reason and only with your express consent; We will not include personal e-mail or postal addresses, or telephone or fax numbers on our website or in printed publications. 5. We may use group images with very general labels, such as "youth enjoying sport" or "making Christmas decorations"; We will only use images of young people who are suitably dressed, to reduce the risk of such images being used inappropriately.Other ArrangementsIs there anyone specific that your young person would prefer to share a tent with?We cannot guarantee that every request will be able to be met exactly.THANK YOU!Please click 'Submit' and then check that there are no additional fields to complete. If your booking has been completed then you will see a confirmation message in the place of this form when the page has refreshed, and will also receive confirmation by email.
