ANNUAL CONSENT FORM

Download Annual Consent Form

June 2007

ANNUAL
CONSENT
FORM

PART A (To be completed by The Boys’ Brigade)

Company:   Ist Dronfield_______________________________________

Officer in Charge:  Tony Drury-Smith_________________________________

Address:   210, Eckington Road, Coal Aston,Dronfield____________________________________

______________________________________________________Postcode:   S183AZ_________

Contact Telephone Number:   01246 415681______ Email:  bb@coalastonmethodist.org.uk_______

It is advised that parents/guardians make a note of the above details.
 

PART B (To be completed by the *Parent/ *Guardian) * please delete as appropriate

Full name of member: _______________________________________________________________

Date of birth: ________________

PERMISSION

I give my permission for _______________________________ (child’s name) to attend and take part in the activities of the company. A list of usual company activities is listed on the back of this form.

Signed: _____________________________ Name: ________________________ Date: ___________

MEDICAL DETAILS

Name and Address of young person’s Doctor: _____________________________________________

____________________________________________ Telephone Number: ______________________

National Health Service Number: ___________________

Details of any medical condition or allergies leaders should be aware of (including any medication needed whilst at BB)?

__________________________________________________________________________________

__________________________________________________________________________________

PARENT/GUARDIAN CONTACT DETAILS

Address: __________________________________________________________________________

______________________________________________________Post Code: __________________

Telephone: (home)________________ (mobile) _________________Email: _____________________

ALTERNATIVE CONTACT DETAILS

Address: __________________________________________________________________________________

_______________________________________________________Post Code: __________________

Telephone: ________________________ Relationship to you (if any) ___________________________

SPECIAL NEEDS

Please give details of any particular needs your child has to enable them to participate in BB activities:

__________________________________________________________________________________

__________________________________________________________________________________

PHOTOGRAPHS

It is possible that BB members may appear in photographs of company activities that will be used for publicity purposes (e.g. Church/Company Newsletter, Local Press, BB Website, etc). Care will be taken to ensure that addresses of individuals are not given but if you would prefer your child not to be included in such photographs please indicate below: ________________________________

If individuals indicate they do not wish to appear in any BB publicity that wish will be respected.

The Boys’ Brigade is registered under the Data Protection Acts. Any parent may request a copy of relevant information held by the Company and enquiries should be directed to Brigade Headquarters.

___________________