Please enter your Child's name
*
First Name
Last Name
Age
*
Date of Birth
*
MM
DD
YYYY
First sibling's name if attending
First Name
Last Name
Age
Date of Birth
MM
DD
YYYY
Second sibling's name if attending - If you have more than 3 children please complete a second form.
First Name
Last Name
Age
Date of Birth
MM
DD
YYYY
SELECT ALL SESSIONS THAT YOU WISH TO BOOK
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Permission
*
I give permission for my child(ren) to attend the activity sessions listed above. In doing so I understand and accept that there may be an element of risk in some of the activities.
In the event of my child being taken ill or injured during any of the activities, I authorise the administration of first aid and for my child to be accompanied to hospital by a representative of the Northern Fells Group. If a form of consent to treatment is required by the medical authorities and delay in obtaining my signature might in the opinion of a doctor or surgeon endanger the health or safety of my child, I authorise a representative of the Northern Fells Group to sign the form of consent on my behalf.
Unless otherwise indicated below on this form, I confirm that my child does not suffer from diabetes, fainting or blackouts, epilepsy, travel sickness, ear trouble, asthma/hay fever or any other allergies or medical condition or disability which may be relevant to the proposed activity nor is my child taking any sort of medicine or medical treatment. (If your child DOES suffer from one of these or another medical condition, you will still need to check the agree box but you MUST complete the medical declaration). Your Doctors details are required below whether your child has a medical condition or not, in case of a medical emergency.
Unless otherwise indicated below on this form, I agree to my child being photographed by the organisers of the event or activities on the day and photos potentially being used for NFG publicity. (If you DO NOT wish your child to be photographed, you still need to check the agree box but you MUST also check the final boxes under 'Photography').
Any personal information supplied to the Norther Fells Group as part of this booking process and/or any other interaction with the Northern Fells Group will be collected, stored and used in accordance with the Northern Fells privacy policy. Further details can be found within the 'Privacy Policy' on the Northern Fells Group website: Northern Fells Rural Community Development Group (northernfellsgroup.org.uk) at the bottom of the “Home Page”.
Name of Parent or Person with Parental Responsibility giving the above consent
*
First Name
Last Name
Mobile and/or landline number(s)
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Name and number of a second contact
*
To be used in the event of an emergency, if we cannot get in contact with the primary contact.
First Name
Last Name
Mobile and/or landline number(s)
*
(###)
###
####
MEDICAL DECLARATION - Further to information stated above in 'Permissions'
Please tick ALL relevant conditions and give details in the box below.
My child suffers from the following condition(s):
Please state which child this applies to, and enter any relevant information or medical conditions not listed above
Please enter any medication with dosage times and amounts, that your child is on
Name of Family Doctor
*
First Name
Last Name
Address of Doctor
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Telephone number of Family Doctor
*
(###)
###
####
PHOTOGRAPHY
*
Please confirm the following:
FOOD PROVIDED AT YOUTH SESSIONS
*
Please confirm the following - I give permission for my child to receive food at the Youth Scheme session(s):
APPLYING SUN LOTION
*
We ask that parents and/or carers apply sun cream to their children before the start of any youth activity day. We also ask that you send your child to the youth scheme with a sunhat (name of child inside please) to protect their head, plus additional sun cream to re-apply if necessary - Please also confirm the following:
CONTACT DETAILS
*
Please confirm the following - I give consent to my contact details (name and email address) being added to a mailing list to keep me informed of future events run by NFG (You may opt out at any point by emailing office@northernfellsgroup.org.uk) :
