Forms Test Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Young Carer Details Young carer name *FirstLastGP Details GP surgery name *GP address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeGP phone number *Medical Consent I consent to my child being offered mild painkillers (paracetamol) should the need arise *—YesNoI consent to my child having plasters applied in the event of injury *—YesNoDoes your child suffer from? Asthma *—YesNoHeart condition *—YesNoEpilepsy, fainting, or blackouts *—YesNoSevere headaches or migraine *—YesNoDiabetes *—YesNoAllergies *—YesNoTravel sickness *—YesNoFear or phobias *—YesNoHay fever *—YesNoIf 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 *—YesNoPlease give details of any other conditions. Does your child have any dietary requirements? *—YesNoIf 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. *YesNoEmergency Contact Information Parent/Guardian *FirstLastAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodePreferred phone number *Alternative phone numberEmail address *Second emergency contact *FirstLastRelationship to your child *Second emergency contact address details *Address Line 1Address Line 2CityState / Province / RegionPostal CodePreferred phone number *Alternative phone numberThird emergency contact FirstLastRelationship to your childThird emergency contact address details Address Line 1Address Line 2CityState / Province / RegionPostal CodePreferred phone numberDate completed *Submit
