Personal details
Which weeks would you like to attend Get With? *
Full name of participant *
Date of birth *
Age *
11
12
13
14
15
16
Gender *
Address *
Postcode *
Home telephone
Work telephone
Mobile telephone
Name of next of kin *
Emergency contact number whilst at Get With *
Name and address of participant's Doctor *
Doctor's telephone number
Name of housing association (if applicable)
Your name *
I confirm that I have parental responsibility for the above named. *
My child is in good health and I consent to him/her taking part in the scheme.
In the event of illness or accident, I consent to any necessary medical treatment, which might include the use of anaesthetics.
I agree that I will be liable for any deliberate damage to any Get With venue or its contents caused by the above named participant. *
I understand that Get With is an open youth provision which means that my child can leave and return to the session at any time. *
I understand that my child is not supervised outside of the Get With venue. This applies even if my child has travelled to another venue using the transport service. *
Free transport
I wish my child to use the free transport service to and from Get With 2011 *
I understand that it is my responsibility for my child getting to and back from the designated pick up points.
If you would like to use the transport service please send a Stamped addressed envelope to: Get With (free transport), Hart Neighbourhood Centre, Dickson House, London Road, Hook, Hampshire, RG27 9DJ.
We will then send you a Get With 2011 bus pass.
Medical form
Has the participant had or currently have any of the following?
If the answer to any of these questions is "yes", please give details.
If it is considered necessary, do you agree to mild painkillers (e.g. paracetamol) being administered? *
Has the participant received vaccination against Tetanus in the last 10 years? *
Is the participant receiving medical or surgical treatment of any kind from either their family doctor or hospital? *
If yes, please provide details
Has the participant been given specific medical advice to follow in emergencies? *
If yes, please provide details
In the event of any illness or medical treatment occurring after the return of this form and prior to the start of the scheme, I undertake to inform the Get With team. *
Consent for taking images
During the scheme we are likely totake pictures and videos. We would like to use these in presentations, displays or in our own booklets, newsletters or publicity.
In the event of any images of my child/me being taken, I consent to them being used for educational and publicity purposes. *
I consent to the images being used on the Hart Neighbourhood Centre website and/or the Sentinel Housing Association website. *
