Formerly St Agnes with St Paul and St Barnabas
Reading Gateway Church Kids Logo

Young Person's Details

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

Medical Details

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 ?
Is your child currently on any medication?
Has your child had any recent broken bones or muscle/ ligament/ joint problems?
Any other Relevant Information (e.g. restricted contact with family members or others)

Parent / Guardian Details

Emergency Contact Details

Emergency Contact 1

Name:

Phone: 

Emergency Contact 2

Parent / Guardian Consent

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 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.

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