Newham City Farm Junior Volunteer Registration Form

Please complete a separate form for each Child and return to Farm staff. Your child will not be accepted without the return of this form but please do contact the Farm on 07584 212391 if you have any problems with this.

Child’s name

Child’s gender male female (please delete as appropriate)

Child’s date of birth

Child’s address

Parent/carer’s name(please state relationship to child)

Home phone number

Work phone number

Contact E-mail

Emergency number(please give two, different to home, work and say whose numbers they are)

Name, address and phone number of your child’s doctor

School attended by child.

Please attach a recent photo of

your child.

Does your child need medication?

Please complete attached medical consent form whether takes medication or not.

Yes no (please delete as appropriate)

Date of last tetanus injection:

Does your child have any disability or educational need? If so please state.

Are there any foodstuffs that your child cannot eat or drink because of diet, religion etc.?Are you willing /able to assist in trips/activities if needed to support the young volunteer scheme and could you provide any transport?Availability to meet Manager or Assistant Farm Manager

Sessions run on Saturday or Sunday between opening hours.

For Farm use: (please tick) (maximum of 5 children each session)Saturday sessionSunday session

Monitoring

The reason we are asking you to give the ethnic origin of your child is for monitoring purposes only. It helps the Farm make sure that all the people of Newham can access our services.

African Asian/African Asian/Indian

Asian/Pakistani

Asian/Bangladeshi

Asian/Chinese

Asian/Other Caribbean/West Indian

British Irish Other Europe Other CountriesWhite & BlackCaribbean

White & BlackAfrican

White & Asian Any Other Mixed Background

Declaration

Please read the statements below carefully. If you have any queries on them or on any of the information in this document please contact a member of staff at the Farm.

1. I have read the ground rules and will support staff and my child in upholding them.

2. I understand the Farm is an open access and this means that staff cannot stop my child leaving the site. All they will do is ask children to inform them when they come and go.

3. I understand that while my child will be under the supervision of staff while on site, and while staff will take reasonable care for the children, they cannot necessarily be held responsible for any loss, damage or injury that may occur to my child in attendance at the Farm.

4. I consent to any emergency treatment that may be necessary during the course of the scheme if in the opinion of the doctor or the dentist, any delay to obtain my signature may endanger my child’s health or safety.

5. On occasions, there may be work-related trips in and around the Borough e.g. to Schools . I agree to my child taking part in these or similar trips.

I agree to the above statements, 1 to 5, and to all the information contained in the complete document (if you do not agree with these or do not fully complete the form and sign it your child cannot attend the Farm Volunteer Scheme.)

PRINT NAME: ________________________________________________

SIGNATURE: _______________________________ DATE: ___/___/___

For office use only - signature of staff and date

SIGNATURE: _______________________________ DATE: ___/___/___

Newham City Farm Medical Consent Form

Does your child need medication? Yes/No

Please list medicines, dosage and their purpose.

These must be given to staff and administered under their supervision at the relevant time.

Will your child need to take these medicines while at the project (if yes, staff may require specialist training)

Yes/No

Does your child have fits/episodes?

If yes how do they present and how do you deal with them.

Yes/No

Does your child have any allergies?

If yes list the type of allergy and it’s symptoms

Yes/No

Date of last tetanus injection

I consent to any emergency treatment that may be necessary during the course of the volunteer scheme, provided that in the opinion of the doctor or the dentist, any delay to obtain my signature may endanger my child’s health or safety.Signature of parent/legal guardian:____________________________(if parent/carer does not sign, child cannot attend.