Downloads Annual Consent

Annual.

June 2007

ANNUAL

CONSENT

FORM

PART A (To be completed by The Boys’ Brigade)

Company: _Ist Dronfield_______________________________________

Officer in Charge: _Tony Drury-Smith_________________________________

Address: ____210, Eckington Road, Coal Aston,Dronfield_________________________________________________________________________

__________________________________________________________ Postcode: ____S183AZ____________

Contact Telephone Number: 01246 415681______Email: __tonydruysmith@btinternet.com__________________________

It is advised that parents/guardians make a note of the above details.

PART B (To be completed by the *Parent/ *Guardian) * please delete as appropriate

Full name of member: ________________________________________________

Date of birth: ________________

PERMISSION

I give my permission for _______________________________ (child’s name) to attend and take part in the

activities of the company. A list of usual company activities is listed on the back of this form.

Signed: _______________________________ Name: ________________________ Date: ___________

MEDICAL DETAILS

Name and Address of young person’s Doctor: ___________________________________________

____________________________________________ Telephone Number: _____________________

National Health Service Number: ___________________

Details of any medical condition or allergies leaders should be aware of (including any medication

needed whilst at BB)?

_____________________________________________________________________________________

_____________________________________________________________________________________

PARENT/GUARDIAN CONTACT DETAILS

Address: ______________________________________________________________________________

_________________________________________________________ Post Code: __________________

Telephone: (home)________________ (mobile) ___________________ Email: _____________________

ALTERNATIVE CONTACT DETAILS

Address: ______________________________________________________________________________

_________________________________________________________ Post Code: __________________

Telephone: ________________________ Relationship to you (if any) ____________________________

SPECIAL NEEDS

Please give details of any particular needs your child has to enable them to participate in BB activities:

______________________________________________________________________________________

_____________________________________________________________________________________

PHOTOGRAPHS

It is possible that BB members may appear in photographs of company activities that will be used for publicity

purposes (e.g. Church/Company Newsletter, Local Press, BB Website, etc). Care will be taken to ensure that

addresses of individuals are not given but if you would prefer your child not to be included in such

photographs please indicate below: ________________________________

If individuals indicate they do not wish to appear in any BB publicity that wish will be respected.

The Boys’ Brigade is registered under the Data Protection Acts. Any parent may request a copy of relevant information held by

the Company and enquiries should be directed to Brigade Headquarters.

___________________