Young People Matter Charity:
Service Application Form

Service User Application Form for Young People Matter's Out of School Services including after school clubs, homework clubs, breakfast clubs, half term provisions and summer camps. For further info see Charity website: http://youngpeoplematter.org

Date:

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* 1. Date:

Today's Date:
Indicate Out of School Service:

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* 3. Indicate Out of School Service:

About Your Child

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* 4. About Your Child

Child's Address

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* 5. Child's Address

How did you find out about the service?

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* 7. How did you find out about the service?

About Parent/Guardian

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* 8. About Parent/Guardian

Parent/Guardian's Address

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* 9. Parent/Guardian's Address

Housing

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* 10. Housing

Social Media Info

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* 11. Social Media Info

Emergency contact details (x2 must be completed or the form will be returned to you)
Please give details of an alternative contact(s) to the above that we may refer to in case of an emergency:
Emergency Contact 1

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* 12. Emergency Contact 1

Emergency Contact 2

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* 13. Emergency Contact 2

Name of Persons Authorised To Collect Child:

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* 14. Name of Persons Authorised To Collect Child:

Does your child have any specific dietary needs or food allergies or intolerances?

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* 15. Does your child have any specific dietary needs or food allergies or intolerances?

Confidentiality: Child’s health, attitude and behaviour
Does your child have any special needs?

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* 16. Confidentiality: Child’s health, attitude and behaviour
Does your child have any special needs?

YPM Equality and Diversity Policy:  The following information is required for monitoring purposes only.
Young People Matter wants to ensure that your child/ren are able to participate as fully as possible. Disclosure of a disability, specific/learning difficulty or health conditions will be used to ensure that reasonable adjustments are made to support your child/ren.
Young People Matter is committed to ensuring that all service users have an exciting and rewarding time within a safe environment while attending our activities. This requires the active co-operation and satisfactory behaviour of everyone involved to ensure that enjoyment of all is unimpaired.
Parent/ Guardian:

  • I have read, understood and fully agree to the terms and conditions outlined in the Young People Matter form
  • I give permission for my child/ren to participate in all activities and understand that certain activities may take place off site. If this is the case, I give my consent for Young People Matter to make the necessary travel arrangements.
  • I have given full and detailed information relating to any medical and dietary needs of my child/ren.
  • I understand that all medication (including self-administered) must be clearly labelled with details of dosage & usage and handed in/and made aware to a Team Leader on site (this includes inhalers). –please refer to our “request to administer medication form.”
  • I understand that I will be financially responsible for any damage, repairs or replacements caused by my child. I will also be responsible for any cost incurred, including travel costs, in the event of my child/ren being asked to leave. 
  • In the event of an emergency where neither I, as parent/guardian, nor my alternative contact can be reached, I agree to medical and dental treatment being administered in accordance with the recommendations of a qualified medical practitioner.  This may also include the administration of a general anaesthetic or surgical operation.

By submitting this form, I give permission for my child/ren to be involved in photography/video and the subsequent reproduction & publishing of, to be used in the promotion of Young People Matter products. Young People Matter regularly takes photographs/videos during sessions. Please inform if you wish non-inclusion.
This form was completed by

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* 19. This form was completed by

T