Doulos Reapplication Form

Doulos 101 Application Form
PART 1 - Contact Info
Name of Young Person *

First Name Last Name
Date of Birth *

- Day - Month Year
Gender *

Male Female

Home Address *

Street Address
Street Address Line 2
City	State / Province
Post Code	Country

Name of Parent / Guardian *

First Name Last 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 *
Parent / Guardian Other 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 T-Shirt Size *
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 Name Last 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
Second Emergency Contact- Name & Relationship to Young Person *
Second Emergency Contact Number *
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? *

Yes No
Date of last Tetanus Immunisation
Please select appropriate answer: *

My child IS NOT actively sensitive to Penicillin My child IS actively sensitive to Penicillin
Doctors Name, Address and Telephone Number: *
I give permission for my young person to take part in Doulos 2018-2019. 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 like to use social networking sites like Facebook and Instagram. The contact we would have on these sites would only ever be in a public domain like our Doulos Facebook groups, or in private messages where another leader will always be copied in.
Are you happy for your young person to be friends with the Doulos leaders on social networking sites if your young person wants this? *

Yes No
I give consent for Doulos leadership to contact my young person about Doulos via: (please tick all that apply) *

Social Media (Facebook/Instagram) Email Text Message I would like to receive a copy of any message that is sent to my young person I 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 used No - 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 *

Yes No (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 *

/ Day / Month Year
PART 5 - Payment Info

The cost of Doulos for the year, including a weekend away, is £150.

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

Tees Valley Youth for Christ
ASIC House
13 Yarm Road
Stockton-on-Tees
TS18 3NJ

Our information for setting up a direct payment or standing order is:
HSBC account number 31371177, sort code 40-47-51
Please tick one payment option *

I will send a cheque/cash for the full £150 payment I will send a cheque/cash for £75 and provide the remaining £75 at the first session in September I have made a direct payment of £150 I have set up a standing order online for £12.50 to be paid over the next 12 months I would like to talk about alternative payment methods/scholarship opportunities
PART 6 - Marrick Priory Residential
My young person will be attending the Doulos residential on the 5-7th of October. *

Yes - they will be attending No - they will not be able to attend
I consent to my young person taking part in the following activities, should they be offered: (un-tick if you do not consent) *

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 Mountain Biking
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.
Parent / Guardian Digital Signature (please type full name) *
Date *

/ Day / Month Year
Should be Empty:

Doulos 101 Application Form