Consent form

The Highland Council
PERSONAL / PARENTAL / GUARDIAN CONSENT FORM
including ADDITIONAL ESSENTIAL INFORMATION

(To be completed by parent/guardian of young people under 16 years of age or participant him/herself if over 16)

Young Person’s Details

Name.................................................................................................. Date of Birth.....................................

Home Address................................................................................................................................................

.......................................................................................................................................................................

..................................................................................... Postcode.................................................................

Telephone number (Home, including STD code)...........................................................................................

Mobile number..............................................................................................................................................

E-mail address...............................................................................................................................................

Medical Details

*I/My child do/es NOT suffer from any medical condition requiring regular treatment.

*I/My child suffers from ................................................................................................................

...................................................................................................................................................................

...................................................................................................................................................................

and requires regular treatment as follows:.....................................................................................................

...................................................................................................................................................................

...................................................................................................................................................................

*I/My daughter/son can administer this treatment *my/her/himself. *YES/NO

Do you consent to medical treatment being given in an emergency? *YES/NO

I agree to my *son/daughter attending Highland Council Youth Events.

Name of * Parent/Guardian (BLOCK LETTERS) ..................................................................................

..................................................................................................................................................................

Signature of * Self/Parent/Guardian .......................................................................Date.............................

Emergency Contact Details (to be completed by all participants, including over 16’s)

Name/s :.......................................................................................................
Emergency telephone numbers :
Home :.................................................................................Work :............................................................

Mobile :....................................................................................................

The Highland Council
PARENTAL / GUARDIAN CONSENT FORM
including ADDITIONAL ESSENTIAL INFORMATION
(To be completed by parent/guardian of young people under 16 years of age or participant him/herself if over 16)

Highland Council Youth events are generally recorded by way of photographs, video or vocal recording which at a later date may be used to promote the Wellbeing Alliance Youth Strategy and/or local youth initiatives/developments. We would be grateful if you could indicate whether or not you are willing to allow any such record of you/your son/daughter to be used for these purposes.

*I give/*I do not give permission for any photographs, video or vocal recordings to be used to promote Highland Council Youth Development Projects/Events.

Signature of * Parent/Guardian/Self ................................................................... Date.........................

Dietary Requirements and Special Needs
*I/My daughter/son do/es NOT have any dietary requirements or special needs.

*I/My daughter/son have/has dietary requirements or special needs as follows:.........................................

.........................................................................................................................................................................

(Please contact me on the number below if you wish to discuss your/your son’s/daughter’s needs)

Any Other Relevant Information – please specify....................................................................................

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* PLEASE DELETE WHICHEVER DOES NOT APPLY
Please Note: We have decided to ask for one form to cover all Highland Council Youth events thus eliminating the need for you to complete a form each time you/your son/daughter is attending a Highland Council Youth activity or meeting.