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 CodeConfidentiality 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 understandDate completed *Submit
