PARENTAL/CARER CONSENT FORM

Name of Young Person:

Address:

Telephone:

Emergency Contact:

Date of Birth:                                                             Age:

Nationality:

Email address for Young Person (all emails will be copied to parental/carer email address):

Parental Email Address:

Would you like to be put on our mailing list:

Please give details of Allergies or Special Needs:

In accordance with our child protection policy we will not permit photographs, video or other images of young people to be taken without the consent of the parents/carers and young people.

To raise the profile of the ESCAPE TUNED-IN work we would like your permission to take photographs and use film for documenting the project.  These images will be used as part of the project activity, making films/videos and photographs will also be used in project reports, displays, evaluation and promotion.  It is important that we have your agreement to do this. 

Please complete the following:

I (parent/carer name)………………………………………………… DO / DO NOT (delete as required) give my consent for ……………………………………………… (young person’s name) to take part in this project.

I (parent/carer name)………………………………………………… DO / DO NOT (delete as required) give my consent for ……………………………………………… (young person’s name) to be photographed and/or filmed as part of this project and for project promotional purposes.

I (young person’s name)…………………………………….. DO / DO NOT (delete as required) give my consent to be photographed and/or filmed as part of this project and for project motional purposes.

Signed (Parent/Carer)……………………………………………………………………..Date………………………………………

Charity Number : 1097718 Company no. 441388, Registered Address: 21 Shakespeare Street, Stratford-upon-Avon, CV37 6RN, Contact Karen Jones: (01789) 293615.

Developed in partnership with Stratford Family Support Team