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.
___________________