summer Stuff 2013 - Young People's Service - Lancashire County ...

COMMUNITY SPORTS ENROLMENT FORMThis form must be completed by a parent/guardian/carer andreturned to the Coach prior to taking part in the activitiesPlease answer all the questionsParticipants Surname: ……………………………………..…………..…Participants First Name: ………………………………………………….Male / FemaleAddress: ……………………………………………………………………..………………………………………………….Post Code: ………….……..Date of Birth: ………………………. Age: ……………………. School Year: ……………CONTACT AND MEDICAL INFORMATIONName of Parent/Guardian/Carer: …………………………………………………………………………………….…………….………………Emergency contact number:……………………………………………………………………………………….…………...Please detail any medical conditions which the coach should be aware of:……………………………………………………………………………………………………………………………………...……………SPORTS EQUITY Please circle your answersDo you consider your child to have a disability? Yes / No If yes, what is the nature of the impairment?Physical impairment Visual Impairment Learning DifficultyHearing impairmentOther, please specify:ETHNICITYWhat is your childs ethnicity?WhiteWhiteMixedAsian or Asian BritishBlack or Black BritishChinese or other ethnic groupPlease tick one of the 6 main categoriesBritish, Irish or any other white backgroundGypsy/Roma, Traveller of Irish heritageWhite and Black Caribbean, white and black African, white and Asian, any othermixed backgroundIndian, Pakistani, Bangladesh or any other Asian backgroundCaribbean, African or any other black backgroundChinese, any other ethnic group not listedPROMOTIONHow did you find out about this programme? Please circle your answerLeaflet Council website Newspaper Other……………….PHOTOGRAPHSUnder changes to child protection law, you must now indicate yes or no if it is ok for official photographers to take pictures of your children whilst they are under oursupervision.Please tick :It is ok for my child to be photographed by an official photographer and for photo and name to appear in any potential publicitythat will help advertise the schemesI do not wish for my child to be photographed at any time.These photos will be used for promotional uses, to help advertise the schemes and programme which we run. The photos may also appear on our official Facebookpage, which allows the young people to gain access to action shot photos of themselves participating in our activities.Thank you for signing up for this activity. Your answers are confidential. We, Wyre Council, will find this personal data useful for monitoring the success of ourprogrammes and to help plan future sports activities for young people. We will not pass this information to any third party or use it for any other purpose than thosementioned. We will collect and process all personal data in line with the Data Protection Act 1998.E-MAILIf you want to receive information about future sports opportunities, please enter your e-mail address below (parent/guardian/carer only)E-mail address: ………………………………………………………………………………………………………………………………………CONSENT STATEMENTPlease delete where necessaryMy son/daughter/ward is in good health and I consider them capable of taking part in the Wyre Council activity. I have completed the medical details and consent that inthe event of any illness/accident, a suitably qualified person can administer any necessary treatment to my son/daughter/ward. I also accept that there are risksassociated with competing in sports events and that the event organisers and team managers and coaches will take every precaution to minimise those risks.Signed ………………….………….……………… (parent/guardian/carer) Name ………………….……..………..………… Date ….………….….19