St John's Youth Club Registration Form - St John's Church Perry Barr

Child/Young Person's Full Name *

Name by which they prefer to be called *

Their date of birth *

M/F/Other *

Full home address and postcode *

Is this child in care? *

Yes

No

Does the young person have any medical conditions about which we should be aware? *

No

Yes

If yes, please state here (e.g. allergies, asthma, epilepsy, travel sickness, diabetes etc)

Please give any details of special dietary needs, if applicable ( or state "none") *

Emergency contact details: please give telephone number(s), name(s), address(es) and relationship (e.g. parent, grandparent, neighbour) of at least one person we can contact in an emergency *

Consent: Please type your name and relationship to the child here, as well as today's date, to indicate your consent to their participating in the Youth Club activities. *

I give permission for my son/daughterâ€™s image (including photographs and videos) to be used on the St John's website or social media platforms *

Yes

No

Our contact phone number is 07907779814. We would like to contact you with news throughout the year, to be informed about events and other information. Are you happy to join the Youth Group WhatsApp group? *

Yes

No

Please insert your preferred phone number for the WhatsApp Group here

If you ticked NO, how would rather be contacted?

Text message

Email

Post

Telephone

Have you read St John's Youth Club's Rules of Engagement? *

Yes