Doulos 101 Application Form

Doulos 101 Application Form

Welcome to Doulos 101! Please fill out the form below and indicate in PART 6 whether your student is able to attend our residential on the 6th-8th of October.
Doulos sessions will be held on the following Monday nights at All Saints' Church in Eaglescliffe (TS16 0AB) from 7pm-9pm (unless otherwise stated). Dates may be subject to change, but advance notice would be given if this ever needs to happen.

18th September
6-8th October (Residential)
23rd October
20th November
18th December
22nd January, 2024
26th February
18th March
15th April
13th May
PART 1 - Contact Info
Name of Young Person*

First NameLast Name
Date of Birth*

DayMonthYear
Which most accurately describes the young person?*

FemaleMaleNon-binaryTransgender
Student T-Shirt Size*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Name of Parent / Guardian *

First NameLast Name
Parent / Guardian Primary Contact Email*
Please note, this is the primary way we communicate about what is happening in Doulos throughout the year, including how we will send travel details for any Doulos residentials/day trips. Please check your junk/spam email folder if you have not received a confirmation email to this address within 2 weeks of sending this application.
Parent / Guardian Primary Contact Number*
Second Emergency Contact- Name & Relationship to Young Person*
Second Emergency Contact Number*
Please tick the box to indicate that you consent to Tees Valley Youth for Christ retaining the information contained in PART 1 of this form. The information will only be used to contact you about Doulos activities and other events that your young person may be interested in. It will not be shared with any other organisations or individuals and it will be held securely by Tees Valley Youth for Christ for a maximum of 18 months.

Tick to Confirm
PART 2 - Student Info
Student Email (OPTIONAL)
This will only be used to contact your student with reminders about upcoming Doulos sessions or events if given permission.
Student Mobile Phone Number (OPTIONAL)
This will only be used to contact your student with reminders about upcoming Doulos sessions or events if given permission.
Name of Church Young Person Attends
Name of Youth Worker at Church

First NameLast Name
Youth Worker's Email
Please obtain permission from youth worker to share this contact email. It will only be used by Doulos to update the youth worker about what your student is learning in Doulos sessions as well as important upcoming dates to be aware of.
PART 3 - Medical Info
Please give details of any medical conditions including allergies and prescribed medications. Please also outline any dietary needs*
Has your child been immunised against tetanus?*

YesNo
Date of last tetanus immunisation if known
Please select appropriate answer:*

My child IS NOT actively sensitive to PenicillinMy child IS actively sensitive to Penicillin
Doctors Name, Address and Telephone Number:*
I give permission for my young person to take part in Doulos 2023-2024. I understand that while attending, my young person will be under the control and care of the leaders and/or other adults approved by Tees Valley Youth for Christ and whilst those in charge will take responsible care of the young person, they cannot necessarily be held responsible for any loss, damage or injury suffered by my young person arising during or as a result of my young person attending. I understand that should my young person require emergency treatment owing to illness/injury and I am not available to give my consent, the doctor or surgeon concerned can decide on appropriate treatment if my young person's health or safety is at risk.*

I Agree
PART 4 - Social Media, Photography & Travel Consent
To effectively communicate with your students about upcoming Doulos activities, we sometimes use our Doulos Facebook and Instagram. The contact we would have on these sites would only ever be in a public domain, or in private messages where multiple leaders will always be copied in.
I give consent for Doulos leadership to contact my young person about Doulos via: (please tick all that apply)*

Social Media (Facebook/Instagram/WhatsApp)EmailText MessageI would like to receive a copy of any message that is sent to my young personI do not give permission to contact my young person
Photographs and video may be taken during Doulos sessions by our designated media team. Pictures and videos may be used in our digital and printed publicity which may include our official social media sites, although your child's name will not be published. Please tick if you consent to this:*

Yes - photos and video may be usedNo - photos and video may not be used
We will provide transportation to and from a pre-arranged meeting point for the residential and some day trips. This transport will be in a car or minibus and priciples from our safeguarding policy will be followed regarding drivers and supervision. Appropriate licenses and insurance coverage will also be obtained.
I give permission for my young person to be transported as above, as necessary*

YesNo (if no, please recognise your young person will need to travel independently or miss out on these activities.)
Parent / Guardian Digital Signature (please type full name)*
Date*

DayMonthYear
PART 5 - Payment Info

The cost of Doulos for the year, including a weekend away, is £180.

Cheques should be made to Tees Valley Youth for Christ.
These can be mailed to:

Tees Valley Youth for Christ
558A Yarm Road,
Eaglescliffe,
Stockton-on-Tees,
TS16 0BX

Our information for setting up a direct payment or standing order is:
HSBC Account Number 31371177
Sort Code 40-47-51

Financial scholarships are available to families unable to afford the full Doulos fee. Please select the appropriate tick below and we'd love to talk with you about what we can offer.
Please tick one payment option*

I have made a direct bank transfer of £180I will send a cheque/cash for the full £180 paymentI have set up a standing order online (for example, £15 for 12 months)I would like to talk about alternative payment methods/scholarship opportunities
PART 6 - Marrick Priory Residential

By selecting 'Yes' please understand that a place for your student will be fully booked and paid for by Doulos. If for an unforeseen reason your student is not able to attend, please let us know ASAP as we would need to find a replacement as we are not able to request refunds once booked.
My young person will be attending the Doulos residential on the 6th-8th October.*

Yes - they will be attendingNo - they will not be able to attend
I consent to my young person taking part in the following activities, should they be offered:

High ropes course, climbing/abseiling, open canoeing, kayaking, raft building, caving, hiking and local guided walks, beck scrambling, gorge walking, team challenge, orienteering, low ropes course, zip wire, archery, and mountain biking
*

Yes - I consentNo - I do not consentThey will not be attending
If there is an above activity you'd be uncomfortable with your young person participating in, please list it here.
I understand that although Doulos leadership and Marrick Priory staff will try to minimise any risk of personal injury within practical boundaries, accidents do happen and all physical activities carry the risk of personal injury. I acknowledge that there is an inherent risk of personal injury in physical activities that will be undertaken as part of this residential. I consent to emergency medical treatment should circumstances demand.
Parent / Guardian Digital Signature (please type full name)*
Date*

DayMonthYear
Should be Empty:

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