Consent Form

For Under 18’s form should be completed by a parent/guardian before your young person can participate in the event detailed below. One form should be completed for each young person. Over 18’s please complete Emergency Contact details and Medical details and consent.

Details Of Event

Venue

Travel Chaperones Info

Name of Child

Home Address

Date of Birth

Home Telephone Number

Parent/Guardian Telephone Number

Separator

Medical Information

Name of Doctor

Doctors Address

Does your son/daughter suffer from any conditions requiring special medical treatment, including medication? If yes, please give details below.

Medical Information we should know about.

We would appreciate an alternative contact name and details (in case of emergency).

Name

Relationship to child (neighbour/aunt etc.)

Street Address 1

Town

Postcode

Phone

Any other comments you may feel useful

Adult Consent and Permissions for under 18s

Please complete permissions for the following. (Please tick appropriate box)

I give permission for Borders Youth Theatre Chaperones to seek emergency medical help.*

I DO

I DO NOT

I give permission for my daughter/son to leave the premises unaccompanied*

I DO

I DO NOT

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Important Information - Photography and Film

From time to time Borders Youth Theatre partnership organisations would like to use photographs of volunteers and young people taking part in activities organised by us. These include newspaper articles, publicity display boards and websites relating to the project and films.

I give permission for the use of images/pictures in reports, displays, articles, films or websites. (Individual names will not be used without additional permission).*

I DO

I DO NOT

Name

Childs Name

You must be over 18 to consent to the above.*

I am over 18 and authorised to submit this form.

Parent/Guardian Email*

Password*

Confirm Password*

Username/Email*

Password*

Remember

Consent Form

Medical Information

Adult Consent and Permissions for under 18s

Important Information - Photography and Film

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