Consent Form

Thank you for completing the medical and emergency contact information form below. Please complete one form per child accessing the project.

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Young Carer Details

Young carer name

First

Last

GP Details

GP surgery name

GP address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

GP phone number

Medical Consent

I consent to my child being offered mild painkillers (paracetamol) should the need arise

I consent to my child having plasters applied in the event of injury

Does your child suffer from?

Asthma

Heart condition

Epilepsy, fainting, or blackouts

Severe headaches or migraine

Diabetes

Allergies

Travel sickness

Fear or phobias

Hay fever

If you have selected YES to any of the above, please give details.

Any other condition that we should be aware of for their time at WYC

Please give details of any other conditions.

Does your child have any dietary requirements?

If you have selected YES, please give details.

Media Consent

I consent to my child being in photos / videos that maybe be published on our website or on our social media platforms to raise the profile of young carers and the services we offer.

Emergency Contact Information

Parent/Guardian

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Preferred phone number

Alternative phone number

Email address

Second emergency contact

First

Last

Relationship to your child

Second emergency contact address details

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Preferred phone number

Alternative phone number

Third emergency contact

First

Last

Relationship to your child

Third emergency contact address details

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Confidentiality statement: I consent to my information being held on a database which is shared with the Hampshire Young Carers Alliance. I accept that the responsibility to provide up to date information is my own and will endeavour to provide this as and when applicable. We will keep all information about your family confidential. However, we will share some information on a ‘need to know’ basis if it will enhance the service provision to your child and family. If we have concerns for the safety or wellbeing of a young person or someone else we will pass this on to authorities without your consent, wherever possible we will endeavour to inform you before we do so.

Yes, I understand

Date completed