Young People`s Registration Form

Young People's
Registration Form
Please complete both sides of this form in BLOCK
CAPITALS
DACORUM BOROUGH COUNCIL SAFEGUARDING
CONFIDENTIAL
Parental/Carer consent form, it is essential this form is completed by the parent/guardian if
the child/young person is under the age of 18 and returned in the pre-paid envelope as
soon as possible. Information is confidential and will be only used for the safety of your
child/young person.
Please tick  each category your child/young person wishes to volunteer for;
Skater Group
Dacorum Youth Forum
Face Painter Group
Youth Action Entertainers
Where did your child/young person hear about this opportunity………………………………………..
Full name of
young person
Address
Post code
Date of Birth
Home Number
Mobile Number
Email Address
Preferred method
of contact
Letter/Email/Mobile/Home Phone
School/college
attending
ILLNESS OR ALLERGIES
Does your child/young person have an illness or allergy?
If you have ticked yes please give details:
Is your child/young person on medication?
If you have ticked yes please give details:
Yes  No 
_____________________________________________
Yes  No 
_____________________________________________
Please note, we will not look after or administer medication to any child/young person during any event
Has your child/young person got a disability or a particular need that we should know of?
If yes please give details_____________________________________________________
Is there any additional information that you feel would be useful for us to be made aware of?
If yes please give details_____________________________________________________
EMERGENCY CONTACTS
Contact Name
1st
2nd
3rd
Doctors name
Doctors address
Doctors telephone number
Number
Relationship
IMPORTANT NOTICE
Please note that if a child/young person suffers illness/injury and the parent/guardian of him/her cannot be
contacted immediately by telephone or otherwise, the staff will make speedy arrangements for their
appropriate care.
I give my consent to Dacorum Borough Council to use any photographs/video footage taken of my child/
young person at any Council event on any date for the sole purpose of the Council publicising its services.
This consent is not time limited nor is there any limit to the number and type of Council publication in which
the photograph/video can appear.
PLEASE PRINT NAME……………………………………………………………………………………………..
Signature……………………………………………………………………………………………………………..
Date………………………………………………………………………………………......................................
I confirm that the child/young person is in good health and I consider him/her fit to participate. I consent to
any first aid treatment required by him/her during the course of the event.
PLEASE PRINT NAME………………………………………………………………………………………………
Signature………………………………………………………………………………………………………………
Date………………………………………………………………………………………........................................
The information you provide will be used to ensure the safety of all participants and may be shared with
other people/organisations involved with the delivery of these activities if appropriate. By signing this form
you are consenting to the Council using the information which you have supplied in the manner stated
above.
Please be aware that under the Children's Act, we are obliged to report any concerns regarding child
protection to the relevant authority.
Thank you for taking the time to complete this form. We will review your details every year, if
your details change in the meantime, please contact us.
Resident Services,
Dacorum Borough Council, Civic Centre,
Marlowes, Hemel Hempstead, Herts HP1 1HH
Tel: 01442 228000
www.dacorum.gov.uk
Please contact us on neighbourhood.action@dacorum.gov.uk