THE LOUNGE CONSENT FORM Name of Young Person*Date of Birth* DD slash MM slash YYYY DD/MM/YYYYAddress* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Emergency Contact: Parent/Guardian - Name*Emergency Contact: Parent/Guardian - Phone*Parent/Guardian Email Address*Emergency Contact Backup - Name*Emergency Contact Backup - Phone*Medical Information*Are there any medical conditions (i.e. allergies, epilepsy, asthma, diabetes, travel sickness etc.) which we should be aware of? (Please write 'None' if none) Please give any details of special dietary needs we should be aware of (e.g. food allergies)*(Please write 'None' if none)Is there anything else you think we should be aware of?I understand that Kingsbridge Youth For Christ are not responsible for my child outside of The Lounge session and location, and that any safety/ travel to and from the building is solely the responsibility of the parent/guardian* Yes No We occasionally take photos of The Lounge for our social media accounts (Instagram and Facebook: @KingsbridgeYouthForChrist). We never take close ups or individual photos. It is possible that your child may feature in these photos. If you do not wish for your child to be included, please tick the box. I give permission for my child to be included in photos I do not give permission for my child to be included in photos I agree to my child participating in youth club and the activities run by the team. I understand that every care will be taken to ensure the health, safety and welfare of my child. I realise and accept that in the event of my child’s behavior adversely affecting the safety of the activity, the team reserve the right to return my child home. Yes No
