Lamplight API response

Young person information

Name of school (if attending)

Family Circumstances

Lone parent family

Minority ethnic family

Family with a disabled adult or child living in the household

Family with mother under 25

Family with a child under 1

Family with 3 or more children

In receipt of universal credit

Household income of £17700 or less

Date of birth

Gender

Gender, other

From P6 onwards, child will be in receipt of free school meals?

Parent/Guardian details

Parent/guardian name

P/G relationship to young person:

P/G home number

P/G mobile number

Alternative emergency contact:

Emergency name:

Emergency home phone

Emergency mobile phone

Medical information

Doctor's surgery

If other, please specify

Tetanus injection

Does your child have Hayfever?

Medical conditions

(Medical) If yes, please give details:

Does the child/young person take any regular medication(s)?

(Medication) If yes, please give details:

Allergies or dietary requirements

(Allergies or Dietary) If yes, please give details:

Are there any activities that the child/young person may not participate in?

(Activities) If yes, please give details:

Is there anything else about the child/young person that we would find helpful to know?

(Anything Else) If yes, please give details:

Consent

I understand that every care will be taken to ensure the health, safety and welfare of my child/young person and have read the accompanying letter.

I realise and accept that in event of my child/young person’s behaviour adversely affecting the safety of activities or others, the staff reserve the right to exclude my child/young person for an appropriate period.

I consent to my child/young person participating in Youth Cafe activities.

First aid (I consent to my child receiving basic first aid from trained youth workers)

Medical treatment (999)(In the event of an emergency, I give consent to youth workers telephoning 999 and to any treatment that the professional medical officer in charge considers essential for me / my child/young person.)

Leave (I give permission for my child/young person to sign out during a session and leave unattended if they chose to.)

Social media (I give permission for my child/young person to use social media e.g. Facebook, twitter and Instagram while participating in activities)

Photos (I give permission for my child/young person to be photographed and/or filmed while participating in activities and for these images to be used in publicity material and/or in the media)

Activities out with the drop-in session

Young Person Membership Information (Please complete all fields)

Other information

Young person information

Parent/Guardian details

Alternative emergency contact:

Medical information

Consent