New Road Youth Club

Individual Application, Record and Consent Form

Name of young person D.O.B  

Address 

Name of parent/guardian

Phone number

Mobile number

 E mail address

Name of additional emergency contact

Relationship to young person

Phone number

Mobile number 

Details of any medical conditions, allergies, dietary needs or any disability which may affect your son/daughter whilst attending youth club

Name and address of GP surgery with which your son/daughter is registered

I give my permission for my son/daughter to attend New Road Youth Club.

I accept and support New Road Youth Club’s Code of Conduct.

I understand that New Road Youth Club is not responsible for the loss/damage of any personal possessions which my son/daughter chooses to bring to Youth Club.

I agree that my son/daughter must remain at youth club until collected from the building by a parent/guardian. 

Signed  

Print name

Date

Please return this form to a youth club leader by hand, or complete on line. (youthclub@newroadmc.org.uk)