Impact Parental Consent Form

Please complete the form below

Name of Young Person

First Name

Last Name

Young Person's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Date of Birth (dd/MM/yyyy)

Gender

Male

Female

Name of School

Home Phone Number

Mobile Phone Number

Name of Parent/Carer

First Name

Last Name

Parent/Carer Email Address

This will be used to keep you up-to-date

Additional Information

Please state if your child has any allergies, requires any special diets, receives regular medication or if there is any other important information about your child we need to know. We may contact you for more information about this.

Emergency Contact Details

In the event of an emergency and we are unable to make contact with the parent/carer, please advise us of someone else who may act as an additional emergency contact.

Emergency Contact Name

First Name

Last Name

Relationship to Child

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Activities Consent

Do you give permission for your child to take part in the activities available through IMPACT, which includes transportation with leaders authorised by Cartsbridge Evangelical Church to use own cars / minibus / public transport, outings, visits, outdoor and indoor activities

Yes

Photography and Publicity Consent

Occasionally photographs/videos of the children/young people are taken during IMPACT activities to be used on social media and for raising awareness of Impact.

Do you give permission for your child to be photographed by an authorised member of the IMPACT leadership team during the course of IMPACT activities

Yes

Do you give permission for images of your child to be used in IMPACT or church publicity including, but not limited to; the church website, church newsletters, newspaper articles, etc.

Yes

Declaration

I have understood and give my consent to the above, until the consent is withdrawn in writing. Any information contained in this form will be treated with respect and confidentiality. Information will be stored securely and used sensitively.

Signature

Please type your name here. This constitutes an e-signature

Date (dd/MM/yyyy)

Impact Consent

Impact Parental Consent Form

Please complete the form below