CYP consent form Yorkshire CYP Activities Consent & Information form A one time form that covers a child or young person for various Yorkshire Quaker youthwork events Step 1 of 7 14% Consent and information formAbout you.You, the person filling in this form. Your name Your relationship to the participant Are you part of a Quaker Community?*Normally this would be a local or area meeting, however, not always Quaker Camps, YFGM and affiliated worshiping groups all count. Yes No Your primary Quaker Community.* About the attending Young Person.Participants Name* Young persons preferred name*Name the participant would like to be known by at the event Young persons address*Young persons phone number (mobile) Young persons email Participant's Date of Birth* Day Month Year Participants sex as given on thier birth certificate*Please state Participant's genderPlease state. Participant's ethnicity Is your young person part of a Quaker Community?*Normally this would be a local or area meeting, but not always, YFHS, Quaker Camps and affiliated worshiping groups all count. Yes No Name of participant's primary Quaker Community.* Your young persons needsDietary informationDietary choices* Omnivore Vegetarian Vegan Vegetarian plus fish (pescatarian) Does your young person have any food allergies and intolerances?* Yes No How would you rate the severity of the allergies/intolerances?*Examples; - Lethal, a peanut allergy for which the participant is required to carry an epi-pen. - Severe, Coeliac disease for which ingestion of gluten would be a painful, residential ending, potentially hospitalising situation. -Moderate, a dairy intolerance that would be uncomfortable if transgressed, but manageable -Low risk, one-offs, a bit of redness round the mouth, something you've not bothered to see the Doc about. Immediately Lethal Severe Moderate Low risk Please give details of allergies and intolerances*Triggers, proximity etc. What should we do if your young person has an allergic reaction?*EpiPen's, antihistamines, that kind of thing... Matters of tasteExperience suggests we can't please everyone at meal times, however its helpful to know things your young people are likely and unlikely to eat. This box comes with the strongest "no promises" disclaimer. We will always cook for medical need, we will try to provide for taste as is reasonable and possible. Physical medical needsDo you consider your young person to be disabled?* Yes No Does your young person have any medical needs we need to know about?* Yes No Please give details*Include names of conditions, how we look after your young person well in the light of these conditions, special measures of reasonable adjustments we need to make to ensure that your young person has a medically safe and happy time with us.Will we need to administer medication for these needs at our events?*Broadly speaking we like to hold and administer important medications at events rather than having young people hold and administer them themselves, however there are exceptions. If you think your young person should self administer their meds, select "yes" and give details in the box that appears. Yes No Please give details*Include name of medications, dosages, times of administration and anything else we need to know. Name of GP Surgery Name* Surgery Address*Surgery Phone Number* Young persons NHS number Permission to administer the following?Check all the boxes you are happy for us to administer. Select All Ibuprofen Paracetamol Anti-histamine Plasters COVID lateral flow test Sting relief Psychological, emotional, social and pastoral needsDoes your young person have SPECIAL or ADDITIONAL psychological, emotional, social or pastoral needs we need to take account of to help them have a safe and happy time at our events?*Youth events, especially overnight events, can be emotionally stretching for all young people, are there things beyond the norm that might make attending harder for your young person? This might be as simple as "its their first time away from home overnight", or more complex needs for which you've sought the help of a therapist, or anything in between. In the case of overnight events the information you give here will be passed to the dedicated pastoral care team. Yes No Please give details.* Emergency contactsThis information enables us to contact those who need informing in the event of an emergency. Please provide contact details for two individuals The first person should be the person who has parental responsibility or guardianship of the participant. The second person should - where possible - be at an alternative address to the first contact.First emergency contact*This should be the person with parental responsibility or guardianship of the participant. First Last First emergency contact: Address during the eventFirst emergency contact: Relationship to the participant*ParentGuardianSocial workerFirst emergency contact: Phone number (mobile)* First emergency contact: Phone number (landline) First emergency contact: Email (one that is checked regularly)* Secondary emergency contact* First Last Secondary emergency contact: Address during the eventSecondary emergency contact: Relationship to the participant* Secondary emergency contact: Phone number (mobile)* Secondary emergency contact: Phone number (landline) In the event of an emergency or accident.Should your child/ward become ill or have an accident, every effort will be made to contact you as soon as possible. In the event of an emergency or accident we will call the emergency services first. Healthcare professionals may give treatment immediately when it is in the young person's best interests. For them to attend the event, you must give the following permission:I give permission for any treatment deemed necessary and in the young person's best interests to be given by healthcare professionals.* Yes Use of dataIn accordance with Data Protection, permission must be granted by the parent/guardians or participant (if over 18) before any images may be taken and used, and for how the personal data can be used. Quakers in Yorkshire uses images of Quakers to attract new members. Good images also encourage people to take part in our activities. We need you to indicate whether you give your consent for images of the participant to be used in printed materials and on our website, social media channels and for 11-18's in videos. We will not identify them by name or local meeting. Some materials may be created with partnership organisations. Should you wish to withdraw your consent to the following at any time, please contact Jo Baynham Jonathonb@quaker.org.ukImage consent*Can we take and use pictures of your young person for publicity and updates? Yes No Publicity consent (you)*Do you consent to the contact information you have provided being used to send promotional information about future events and opportunities? Yes No Publicity consent (your young person)*Do you consent to the contact information you have provided being used to send promotional information about future events and opportunities to your young person? Yes No Event ConsentsPlease read and indicate your consent below: Select All I understand that in the event of serious misbehavior that I might have to come and collect my young person from an event. I understand that the information given here will be used to look after my young person and I have filled this form honestly and completely. I understand that the Children Act (2004) requires that if a volunteer is concerned about the safety of a participant (or the safety of someone known to them) they are REQUIRED to inform the QiYs Safeguarding Coordinator. I understand where relevant the information on this form will be shared with hired venues, and if necessary with healthcare professionals. Signature and event consents*To be completed by the parent/ over 18 participant/ or legal guardian or social worker. I have read the guidance and information on this form and have completed all relevant sections accurately and in full. I give my consent to the statements and requirements on this form and for the named participant to attend as stated. If you would like any further information or have any questions about any part of this form please contact Jo Baynham jonathonb@quaker.org.uk. First Last CommentsThis field is for validation purposes and should be left unchanged.
