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Consent Form for virtual and in-person support

These questions should be completed by the parent/guardian of the child(ren) who are receiving support from us.

If a parent/guardian is required to attend alongside their child (for example, our A Day to Remember or Family Group programmes) then the adult who is attending should complete this form.
If your child is of secondary school age or older you are not required to attend their sessions.

If you have problems with this form, or need help completing it, please get in touch.

Your information will be kept safe and confidential. If you have a question about why we collect this information, how we use your information or how we keep it safe then please ask a member of the Treehouse team or see our privacy policy at www.wiltshiretreehouse.org.uk

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* 1. THE CHILD / CHILDREN

Please write the full names and dates of births of each child taking part in our sessions

(e.g. Harrison Smith 25.08.2012, Megan Smith 03.03.2014)

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* 2. What is the child's / children's address? (not including post code)

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* 3. What is the post code?

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* 4. Does the child (or any of these children) have any dietary requirements or allergies?
Please write yes or no in the box below. If yes, please write what the dietary requirements/allergies are.

If you have more than 1 child attending with a dietary requirement or allergy please write the child's name alongside the details. E.g. Charlie - dairy intolerant, Cody - allergic to nuts

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* 5. Does the child (or these children) take any medication?
Please write yes or no in the box below.
If yes, please write what medication the child takes.

If you have more than 1 child attending who takes medication please write the child's name alongside the details.

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* 6. May we use a plaster if needed?

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* 7. PARENT/GUARDIAN

What is your name? (the parent/guardian)

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* 8. Does the child live with you (the parent/guardian)?
Please write yes or no in the box below.
If no, please write your address including post code.

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* 9. What is your email address?

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* 10. What is your home (landline) phone number?
If you don't have one write 'None'

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* 11. What is your mobile phone number? 

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* 12. If you (the adult) are attending our sessions alongside your child please complete this question - for example, our A Day to Remember or Family Group programmes.
For secondary school aged young people (or older) please skip, as you are not required to attend. Please write N/A in the box to enable you to proceed.

Q. Do you (the parent/guardian) take any medication?
Please write yes or no in the box below.
If yes, please write what medication you take.

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* 13. If you (the adult) are attending our sessions alongside your child please complete this question.
For secondary aged young people (or older) please write N/A in the box to skip.

Q. Do you (parent/guardian) have any dietary requirements or allergies?
Please write yes or no in the box below.
If yes, please write what dietary requirements and/or allergies you have.

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* 14. We want to make our programmes as accessible and fair as possible.

Do any of the individuals attending have a disability, sensory need or learning need? Please include children and adults.

If yes, please write the name of the individual and details. If none please type 'none'.

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* 15. PHOTOGRAPHY/FILMING CONSENT

From time to time we may like to take photographs or to film our sessions. This could be because we want to provide you with a record of your time with us, or because we need to provide evidence of the work that we do to our funders. Or it might be because we want to show new families or the general public the work that we do, so that more people can understand the help we offer.

Before we can take photographs or make films we need to obtain your consent.

Do you give consent for us to take photographs and to film you and/or your child(ren)?

You can change your mind at any time by simply emailing us (our email address can be found on our website).

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* 16. Do you consent to your photographs or films being used for publicity purposes (including but not limited to fundraising reports, our website, social media, press releases, and publicity material). 

Remember, you can change your mind at any time.

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* 17. EMERGENCY CONTACT

We would only contact this person in an emergency situation, for example if we could not get hold of you (the adult) or if you (the adult) became unwell in a session.

Please provide the name of an emergency contact, along with their telephone number and their relationship to the child

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* 18. COVID-19

We will provide in-person programmes where possible, in line with Covid-19 guidance.

Please complete our Covid-19 questions so that you (the adult) and/or your child(ren) can attend in-person meetings, sessions & events when safe to do so.  

Q. Is anyone who will be taking part in our sessions classed as being at higher risk of serious illness from Covid-19? Include any adult or child who may attend a meeting or session.

People who are at higher risk include those with the following conditions: 
  • long-term lung conditions (such as severe asthma, COPD, bronchiectasis and cystic fibrosis)
  • long-term conditions affecting the heart or blood vessels (such as congenital heart disease, heart failure and peripheral arterial disease)
  • diabetes
  • chronic kidney disease
  • long-term liver conditions (such as cirrhosis and hepatitis)
  • conditions affecting the brain or nerves (such as dementia, Parkinson's disease, motor neurone disease, multiple sclerosis, epilepsy, cerebral palsy or stroke)
  • learning disabilities
  • a condition or treatment that makes you more likely to get infections (such as HIV or some treatments for lupus, psoriasis or rheumatoid arthritis)
  • severe mental conditions (such as schizophrenia and bipolar disorder)
  • severe obesity (a BMI of 40 or above)

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* 19. If you have chosen yes to the previous question please provide more details - who is at higher risk and what puts them in this category?

This will help us to understand if we need to put extra measures in place to keep them as safe as possible.

If you chose no please proceed to the next question (you may need to click the OK button or scroll down - depending on how this displays on your screen)

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* 20. COVID-19

Is anyone clinically extremely vulnerable? Include any adult or child who may attend a meeting or session.

You're considered clinically extremely vulnerable if:
  • your doctor or GP has classed you as clinically extremely vulnerable because they think you're at high risk of getting seriously ill
  • you've been identified as possibly being at high risk through the COVID-19 Population Risk Assessment
  • you've had an organ transplant
  • you're having chemotherapy or antibody treatment for cancer, including immunotherapy
  • you're having an intense course of radiotherapy (radical radiotherapy) for lung cancer
  • you're having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
  • you have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
  • you've had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
  • you've been told by a doctor you have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
  • you have a condition that means you have a very high risk of getting infections (such as SCID or sickle cell)
  • you're taking medicine that makes you much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)
  • you have a serious heart condition and are pregnant
  • you have a problem with your spleen or your spleen has been removed (splenectomy)
  • you're an adult with Down's syndrome
  • you're an adult who is having dialysis or has severe (stage 5) long-term kidney disease


(list from https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/who-is-at-high-risk-from-coronavirus-clinically-extremely-vulnerable/     20th May 2021)

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* 21. If you have chosen yes to the previous question please provide more details - who is in the clinically extremely vulnerable category and what puts them in this category?

This will help us to understand if we need to put extra measures in place to keep them as safe as possible.

If you chose no please proceed to the next question (you may need to click the OK button or scroll down - depending on how this displays on your screen)

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* 22. COVID-19

We have made a plan to manage the risk presented by Covid-19.

No plan can make in-person activities 100% safe but we will provide the safest environment possible. 

EVERYONE has a personal responsibility and we must all play our part in maintaining a safe environment. 

If you attend an in-person meeting or programme we will email your our action plan for keeping everyone as safe as possible. You MUST read our plan. It will tell you about the things we will do to keep you and others safe, and the things that you and your child(ren) will be expected to do.

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* 23. FINAL DECLARATION: 

I hereby consent to my child(ren) named above receiving bereavement support from Wiltshire Treehouse.

I agree to inform Wiltshire Treehouse in good time if we cannot attend, so that our place can be offered to a grieving family on the waiting list.

The information I have given is correct to the best of my knowledge.

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