Extreme Wheels Parental Consent Form - Safer Derbyshire

Application,
Personal Information
and Consent Form
For all Extreme Wheels Activities
Participant details
Name
Address
Please write clearly in ink
Date of birth of participant
D D M M Y Y
Age
Post Code
Contact telephone including STD code
Email address:
Details of person to contact in an emergency
Name
Address - if different from that already given
What relationship with the participant - eg. Mother, Father, Grandparent, Carer
Emergency contact number(s)
Home
Mobile
Activities
Extreme Wheels may deliver the following activities:
• Mobile Skate Park • Scooter Roadshow • KMX Karting
• Master Blaster Laser Quest • BMX Racing • Body Zorbing
• Mobile Climbing Wall • Whacky Wheels • Trail Riding
• Cycle Maintenance • Whacky Olympics • Go Ride

For Signature
Medical Information
Medical Information
Please list any medical conditions, allergies or disabilities that we should
be aware of. List any medication needed and ensure participants have
correct medication and equipment with them. e.g. inhalers.
Photography
Do you consent to the attached photography statement? Page 4
YES
NO
Data Protection
Do you consent to the attached Data Protection statement? Page 3
YES
NO
Extreme Wheels sessions:
Where did you hear about this course?
Emergency treatment consent (Compulsory - please delete as appropriate)
I give permission for myself / child to participate in the course/activity/
session organised by Bolsover District Council. I consent to myself / child
receiving emergency medical treatment where deemed necessary by
staff. If my child is to receive emergency medical treatment it is on the
understanding that I am contacted as soon as is reasonably possible.
Signed
Date
This document is available in large print and other formats from any of the
Council Offices or by contacting the Health and Wellbeing Directorate
on ( 01246 593068

Please retain this section
Behaviour
Family members may attend the Extreme Wheels sessions as spectators, but
they must not attempt to make contact with their or any other children, or
take any action to distract them, unless there is an emergency situation or
they have been instructed to do so by staff. Parents or carers should likewise
inform their children that they should not attempt to make any contact with
family members during the course/activity/session. Family members and
participants should exercise the principles of fair play, tolerance and respect
at all times. All participants agree to follow the instructions of staff at all
times during the course or activity. We reserves the right to exclude or refuse
admission to any participant from any course/activity/session on the grounds
of disruptive, discriminatory, offensive or violent behaviour or actions that may
be considered to be a danger to themselves, staff or other participants.
We welcome your constructive comments about our course/activity/sessions.
Child Protection
We operate a Child Protection Policy, if you have any concerns about any of
our sessions then please telephone the Joint Assistant Director of Leisure and
Culture on 01246 593056 or email enquiries@bolsover.gov.uk.
Data Protection
All personal information provided to Bolsover District Council will be held
and treated in confidence in accordance with the Data Protection Act
1998. It will only be used for the purpose for which it was given but may
be shared with other Council departments or third party organisations.
The Council may contact you by email or post to ask you about the quality of
our services or to give you information about our activities, which might interest
you. If you do not want to be contacted for that purpose, please tick this box:
For those with smart phones, please scan this Quick
Response (QR) Code so your phone can read it and it will
then go straight to the URL with the information you need
about Extreme Wheels. For information on where we are
going to be or information on cancellations due to weather
please scan QR code or visit:
www.bolsover.gov.uk/extreme-wheels

Registration and Collection
• There is potential risk of injury from the activities and services Extreme Wheels
offers.
• Participants engage in the activities at their own risk. Helmet protection is
compulsory and should be worn AT ALL TIMES whilst taking part in activities
where applicable.
• Parents and legal guardians must consent to their child signing themselves in
and out of sessions.
• Parents and carers have responsibility to drop off and collect their children at
the appropriate times.
• Parents or legal guardians must accompany and supervise children under 9
years of age for the duration of the session unless otherwise stated.
• The council does not accept responsibility for participants until they have been
properly signed in and parents/guardians must be aware that participants are
free to come and go throughout the session.
• Neither Bolsover District Council nor its employees or agents shall be
responsible for any loss, theft or damage to valuables or any personal property
that belongs to any person whilst on the venue area.
• Participants will understand that in the event of an accident, loss or damage,
Bolsover District Council will only accept liability where the accident, loss or
damage is caused by the negligence of the District Council, its employees,
agents or subcontractors.
Equipment hire
Participants hiring equipment do so at their own risk. We cannot guarantee the
equipment is in exactly the same condition as first purchased but make every
effort to record and maintain equipment before and after every hire. Therefore
participants must understand they accept the hire equipment in its current
state. If you require a specific check on any equipment before hire please ask
staff before using the equipment. Bolsover District Council will only accept
liability where the accident, loss or damage is caused by the negligence of the
District Council, its employees, agents or subcontractors.
Any participant who uses their own equipment does so at their own risk.
Photographs
Occasionally photographs of our course/activity/sessions may be taken for
the purposes of general publicity by authorised staff. We will ensure that
visual contents or captions cannot be used as a means of identifying or tracing
children and that the attire or posture of the person(s) being photographed is
appropriate. Where names are required i.e. a young person receiving an award
then specific consent will be sought from the parent/carer. Please refer to Data
protection statement.