Young Person's Details

First Name

Last Name

Date of Birth

Young Person's Email

Enter your child's if you would like them to receive correspondence for this account.

Kids Church (Sundays)

Kids Club (Mondays)

Medical Details

Family Doctor Name

Family Doctor Phone

Family Doctor Address

Address Line 1

Address Line 2

City

County

Has allergies?

Does your child suffer from asthma, diabetes, any allergies ( e.g. to plasters, medicines, foods etc. ), or have any health requirements of which we should be aware ?

Yes

Please provide more details

On medication?

Is your child currently on any medication?

Yes

Please provide more details

Has joint-related problems?

Has your child had any recent broken bones or muscle/ ligament/ joint problems?

Yes

Please provide more details

Other details

Any other Relevant Information (e.g. restricted contact with family members or others)

Parent / Guardian Details

First Name

Last Name

Mobile Phone

Home Phone

Address

Address Line 1

Address Line 2

City

County

Post Code

Emergency Contact Details

Primary Emergency Contact is the same as above

Emergency Contact 1

Name:

Phone:

Name

Phone/Mobile

Emergency Contact 2

Name

Phone/Mobile

Parent / Guardian Consent

I consent to my child taking part in Reading Gateways Kids Work activities. I understand that the activities include activities of a physical nature, activities are subject to appropriate risk assessment.

I understand that he/she will be in the care of the Kids workers, and that, while the Kids workers will take all reasonable care of the young person, they cannot necessarily be held responsible for any loss, damage or injury arising during or as a result of an event.

Hospital Treatment

In the event of illness or accident requiring hospital treatment, I authorise/ I do not authorise the youth workers to sign, on my behalf, any written form of consent required by the hospital if the delay required to obtain my signature is considered inadvisable by the doctor concerned.

I authorise

I do not authorise

Photo Consent: Reading Gateway - Communications

I consent / I do not consent to photo/video images being taken of my child by Reading Gateway during activities, to be shared within the group, to be used for external communications (including website & social media). Last names will not be used with any such images.

I consent

I do not consent

Reading Gateway Church takes your privacy seriously and will only use information gathered here that meets the specific responsibilities as set out in the General Data Protection Regulations (GDPR). Our Data Protection Notice can be obtained by contacting parishoffice@readinggateway.church. Your data will be stored and used in accordance with this policy. We may take photographs at our events to use in displays and in publicity (website, leaflets etc.) If you do not want to be in any photographs or videos, please do let the event leader know. We will not use any names to identify you without your consent.I have read and understand the above statement.

Young Person's Details

Medical Details

Parent / Guardian Details

Emergency Contact Details

Emergency Contact 1

Emergency Contact 2

Parent / Guardian Consent

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