Please enter your Child's name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

First sibling's name if attending

First Name

Last Name

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

Date of Birth

MM

DD

YYYY

SELECT ALL SESSIONS THAT YOU WISH TO BOOK

Week 1

Friday 15th AUGUST - Ernest Cook (Mungrisdale) – Nature activities - Open to 11 - 13 year olds - ONE SPACE LEFT

Friday 29th AUGUST - Go Ape (Whinlatter Forrest) - Open to 11 - 16 year olds - FULL

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”.

I agree

Name of Parent or Person with Parental Responsibility giving the above consent *

First Name

Last Name

Mobile and/or landline number(s) *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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) *

(###)

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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):

Diabetes

Epilepsy

Fainting or Blackouts

Travel Sickness

Ear Trouble

Asthma/Hay Fever

Any other allergies (including food allergies)

Any other medical condition or disability you consider to be relevant

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 *

(###)

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PHOTOGRAPHY *

Please confirm one of the following:

I DO NOT CONSENT to my child being photographed by the organisers of the event or activities and I confirm that I or my child will make this known on the day

I DO CONSENT to my child being photographed by the organisers of the event and to these photos potentially being used for NFG puplicity materials; the website, leaflets, the annual report, social media etc.

FOOD PROVIDED AT YOUTH SESSIONS *

Please confirm one of the following - I give permission for my child to receive food at the Youth Scheme session(s). Ernest Cook will provide a free lunch and snacks during their activity days - For the Go Ape session a packed lunch will be required, however hot & cold drinks, ice cream and cakes will be available free of charge :

YES

NO

PERMISSION TO SHARE THE CONTENTS OF THIS BOOKING FORM WITH THE ERNEST COOK TEAM IF YOUR CHILD IS BOOKED ONTO ONE OR OTHER OF THEIR SESSIONS *

This information will be held securely and confidentially by Ernest Cook for the sole purpose of safety and management of your child whilst attending their activity session. It will not be passed on or used for any other purpose.

YES

NO

NOT APPLICABLE - My only wishes to attend the Go Ape session

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) :

YES

NO