Hello Future Summer Residential Derwent Hill, Keswick 20th – 23rd July 2020

SECTION ONE – Student Details

Full Name

Gender

School Name

Home Address and Postcode

Student Email Address

Student Mobile Number

Date of Birth (DD/MM/YY)

How did you find out about this activity?

Dietary Requirements

Medical or Physical Disability, Mental or Emotional Illness or SEND Considerations

[Please give as much detail as possible including any lists of medications and how these need stored]

Please specify how Hello Future staff can support you whilst of programme with us

[Complete if you have declared anything within the section above]

SECTION TWO – CONSENT TO ATTEND (To be signed by Parent/Guardian if under 18)

I ______________________________ [INSERT FULL NAME], Parent/Guardian of ___________________________

Hello Future Summer Residential Derwent Hill, Keswick 20th – 23rd July 2020

[INSERT STUDENTS FULL NAME] give consent to attend the above activity.

I give Hello Future and its Partners, permission to take photos/film and/or comments of/from me/my child for promotional purposes. Including without limitation, these images may appear on websites, email newsletters, social media, and printed materials (including leaflets, posters and adverts) in materials sent out to the media, and/or in reports and general marketing. We will not include any personal email addresses, postal addresses and/or telephone numbers on our website or in printed publications. Please note that websites can be seen throughout the world, and not just in the United Kingdom, where UK law applies.

Signature (Parent/Guardian if under 18)

Date

Emergency Contact Name Relationship

Emergency Contact Number

Any Additional Information

The emergency contact information will only be used in relation to the above Hello Future opportunity.

(To be signed by Parent/Guardian if under 18)

SECTION THREE – CONSENT TO TREAT IN CASE OF AN EMERGENCY (To be signed by Parent/Guardian)

I ______________________________ [INSERT FULL NAME], Parent/Guardian of ___________________________ [INSERT STUDENTS FULL NAME] give consent that in the event of illness/accident requiring emergency hospital treatment, I authorise the Hello Future Programme to sign, on my behalf, any written consent required by hospital authorities if the delay to obtain my own signature is considered inadvisable. 

Signature (Parent/Guardian if under 18)

Date