New Road Youth Club
Individual Application, Record and Consent Form
Name of young person D.O.B
Name of parent/guardian
E mail address
Name of additional emergency contact
Relationship to young person
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.
Please return this form to a youth club leader by hand, or complete on line. (email@example.com)
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