Child/Youth General Consent Form
This form is for young people ages 4 to 18 who are attending any child/youth programme at Breck Road Baptist Church.
Child/Youth Information
Please be sure to enter the information for each child accurately.
Child's Name
*
First Name
Surname
Child's Birth Date
*
Please select a day
1
2
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4
5
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Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2015
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2013
2012
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current School Year
*
Please Select
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
College
I give my permission for a DBS leader of Breck Road Baptist Church to contact my young person concerning events that are on, lifts, etc. via their mobile and/or social media accounts, as needed.
Yes, that is fine.
No, I would rather not.
If yes, child's mobile number
Medical or other information we may need to know about the child (including food allergies and or medication). For none, type 'NONE'.
*
I give permission for my young person to be taken to hospital and/or given the appropriate treatments required should a serious injury or illness occurs whilst at an event hosted by Breck Road Baptist Church. I agree to not hold Breck Road Baptist Church nor it's leaders responsible.
*
Yes
Parent/Legal Carer Information
Please make sure all data is entered correctly in case of emergency, as well as to receive updates about cancellations, special events, etc.
Parent/Carer Name
*
First Name
Surname
Parent/Carer Mobile Number
*
Parent/Carer Email Address
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
County
Post Code
General Permissions
I hereby give permission for my young person(s) to use the transportation provided by Breck Road Baptist Church to be escorted to and from the event(s) in which my young person is participating.
*
Yes
I hereby give permission for my young person(s) to be given sweets and/or other snacks (in accordance with their medical/allergy needs as listed above) whilst attending the event(s) in which my young person is participating.
*
Yes
I hereby give permission for photographs/video in which my child appears (in accordance to the safeguarding policy of Breck Road Baptist Church) to be used by the church and its affiliated ministries in printed and/or electronic media (i.e., the church website and social media accounts).
*
Yes, that's fine.
No, I would rather not.
I understand that should my young person(s) not adhere to the rules of Breck Road Baptist Church that I may be contacted to collect my young person or my young person(s) may be returned home early from an event. I understand that I am responsible for any damages caused by my young person(s) to the church property/transportation.
*
Yes
Submit
Parent/Carer Signature
*
Date
*
-
Month
-
Day
Year
Date
As an added safety feature for enrolment into the children/youth events at Breck Road Baptist Church, please take a photo (head/face only) of the young person for our secure safeguarding system.
*
Should be Empty: