Young Person's Information

Young Person's Information
Name*

First NameLast Name
Date of Birth

DayMonthYear
School
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Young persons Mobile
Medical Information
Please note down any medical problems we should know about, including allergies, and any medication your child requires
Please note down any special dietary requirements:

Parent / Carer Information*

Contact 2 is optional. Please enter N/A in fields you are not providing.
Consent

Please tick the following boxes to give your consent; you are welcome to leave blank those you do not consent to. If you have any questions, please get in touch.
I give permission...

for the named person above to attend activities organised by Hub104 and King's Church Edinburgh, and related partner organisations.for first aid treatment to be administered as required, and for the appointed leader to authorise urgent medical treatment should I be unreachable to make a decision myself.my child’s photos to be used for publicitythe Hub104 youth team to contact my child via phone / messaging in relation to events / activities they are involved in
I confirm that the medical information given here is correct, and that I will notify Kings Church of any subsequent changes as soon as possible.
Thankyou for completing this form. One of our team may be in touch to confirm details over the phone.
Should be Empty: