Young Adult Carers - Consent Form

If you would like to access the Adult Young Carer group can you please complete the following information so that we are aware of any medical / health needs and have your emergency contact details. We will keep you informed you of activities via direct contact, newsletter, and our social media platforms.

YAC Consent Form

Personal details

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone number *

Email address

Emergency contact 1

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relationship to you *

Telephone number *

Emergency contact 2

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Relationship to you

Telephone number

Medical details

GP name *

Surgery address *

Surgery telephone number *

Surgery email

Extra details

Any extra help we need to provide (for example because of a disability)

Do we need to know about any medical conditions or allergies? (If yes, please provide details of the condition(s) and any medication needed)

Is there anything else you think we should know?

Information

NEWCIS aims to provide a safe and enjoyable experience for every young person. To help us do this, please note the following important information. a. All questions on the consent form must be completed and signed by carer before being able to access the group b. Please ensure that you notify us of any changes to the information given on the form. c. We cannot take responsibility for any damaged clothing and/or personal items during the activity. d. Please ensure you have sufficient water, food, clothing, sun lotion and medication (where appropriate) for the duration of the activity. e. There is an expectation that you will not attend the group under the influence of any alcohol or drugs. If you do you will be asked to leave. This is to ensure the safety and wellbeing of all at the group f. If your behaviour is such that it is placing yourself or others at risk of harm then you will be asked to leave the activity and your continuing attendance at the group will be discussed with you.

I agree to (please tick) *

NEWCIS keeping a record of this form for health and safety reasons
Any medical treatment being sought on my behalf in an emergency
Being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity. Note: if consent is not given, NEWCIS will not use any images taken during the activity that contain you

Print name *

Signature *

Date *