ANNUAL CONSENT FORM
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June 2007 ANNUAL 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. ___________________ |