Youth Work Parental Consent Form

Dorchester Family Church complies with the Data Protection Act 1998. All of the data given
on this form will be held and used in accordance with this Act.
Childs name:

Surname:

Date of birth:

Name(s) of parent(s) who have parental responsibility for the child:

Address:

Home phone:
Parent/Guardian first number for contact mobile:

Parent/Guardian second number for contact mobile:

Parents e-mail:
Young persons e-mail:

Young persons mobile:

SECTION 2 - Medical
Family doctor:

Doctors address and phone number:

Please give details of any health problems, medical conditions or allergies affecting your child, any medication that
they are taking or any disabilities they have that may affect normal activity (continue on separate sheet if necessary):

I give permission for sticking plaster to be used on my child when necessary

I give permission for paracetamol to be given to my child if necessary
This form may only be used by Dorchester Family Church, Registered charity no. 1051454
Agriculture House, Acland Road, Dorchester, Dorset, DT1 1EF
Tel: 01305 265775, e-mail: office@dfc.org.uk web: www.dfc.org.uk

SECTION 3 - Church Travel Consent

I give permission for my child to travel in the car of a youth worker or another parent. I understand that seat belts will
be worn and that the Dorchester Family Travel policy will be adhered to (please see website for more details).
Signature:

Date:

Parent or other adult with parental responsibility

SECTION 4 Overall Consent

I give permission for my son/daughter to take part in the normal weekly activities of Ignite/Fusion. I understand
that the leaders will take all reasonable care in looking after my son/daughter but they cannot necessarily be held
responsible for any loss or damage to property. Youthworkers will adhere to the Dorchester Family Church child
safeguarding policy (please contact the church office for more details) In addition to meeting in a home, hired
venue or church office, normal activities could include any of the following: walking, night walk, ice-skating, cinema,
swimming (pool or beach), trip to beach, cycling and kayaking.
I give permission for Dorchester Family Church to process the personal data given on this form for use in relation to
my child attending Ignite/Fusion and taking part in other activities within Dorchester Family Church.
As part of Ignite/Fusion we will communicate to your son/daughter via text/ e-mail/ online social media adhering to
Dorchester Family Church online policy for Youthwork (please see website for more details).
In an emergency, if I cannot be contacted despite all reasonable attempts to do so by the leaders, I give
permission for my son/daughter to undergo emergency medical/dental treatment including the use of anaesthetics
as considered necessary by the medical authorities.
Signature:
Parent or other adult with parental responsibility

Date:

My child can swim 50m unaided. Please answer yes or no.

SECTION 5 - Photography/video
From time to time we may like to use photographs and/or videos of young people taking part in Ignite/Fusion
activities in publicity for these groups, or we may wish to pass on material for use in publicity, publications,
promotional/training videos and websites produced by Dorchester Family Church. No personal details, such as
names, appear with photographs or videos unless we obtain specific parental permission first.
If you are happy for us to use photographs and/or videos of your son/daughter in this way, please sign below.
If you do not wish us to use photographs and/or videos of your son/daughter in this way then please cross through
this section.
I consent to photographs/videos of my son/daughter being used within Dorchester Family Church for the purposes
mentioned above. I understand that their name or other personal information will not be used unless my permission is
obtained first.
Signature:
Date:
Parent or other adult with parental responsibility

Thank you!