Contact & Permissions Form

< back

This form is to be completed by the parent/guardian if the young person is aged 17 or younger or by the young person themselves if 18 or over. We will not pass your details onto any third party.

1) Personal Contact Details

Full name of young person

Gender

Date of Birth

Address

Post Code

Telephone Number

Mobile Number

If the participant is aged 17 or under, are you happy for SeaChange Arts to contact the young person via their mobile phone or email address, regarding information relating to classes or events?

Ethnicity

Continue

2) Health Details

Does the young person have any additional needs, e.g. any disabilities, or learning difficulties?

Please provide details

Does the young person have any medical conditions or known allergies?

Please provide details

Has the young person ever broken any bones or undergone medical procedures?

Please provide details

Are you happy for SeaChange Arts staff or person contracted by SeaChange Arts to administer first aid if the young person injures themselves?

In the event of an emergency, are you happy for SeaChange Arts staff or person contracted by SeaChange Arts to accompany the young person to hospital or for the emergency services to be called?

Go Back Continue

3) Emergency Contact Details (Parent/Guardian)

Name of Parent/Guardian

Relationship to Young Person

Address (If different to young person)

Post Code

Telephone Number

Mobile Number

Go Back Continue

4) Second Emergency Contact Details

Name of Contact

Relationship to Young Person

Address (If different to young person)

Post Code

Telephone Number

Mobile Number

Go Back Continue

5) Travel Details

The young person/I will be collected at the end of the session.

The young person / I will be regularly collected by:

Please state how, (i.e. walking/ public transport):

During breaks, the young person has/ I have permission to leave the premises.

Go Back Continue

6) Media Consent

On occasion SeaChange Arts may wish to photograph, record or quote participants, these materials may be used for promotional purposes or be shared with funders/ partners.

I give permission for images/ recordings/ quotes of the above named young person/ myself to be taken and used as described above.

Go Back Continue

7) Responsibility Details

Are you a parent or guardian?

For Parent/Guardian to complete if young person is aged 17 or under:

I understand that as Parent/ Guardian of the above named young person it is my responsibility to inform SeaChange Arts staff of any changes to the information stated on this form, including medical information, contact and travel details.
I understand that SeaChange Arts holds a Child Protection Policy and that it is available to me should I wish to read it.
I know and understand the risks involved in circus and physical activity and give permission for the above named young person to take part in this activity.

Name

Date

For young person to complete if aged 18 or over:

I understand that it is my responsibility to inform SeaChange Arts staff of any changes to the information on this form, including medical information, contact and travel details.
I understand that SeaChange Arts holds a Child Protection Policy and that it is available to me should I wish to read it.
I know and understand the risks involved in circus and physical activity and accept responsibility for my participation in these activities.

Name

Date

Please review the Drill House code before your session.

Go Back