WELFARE

Parental/Guardian Consent Form

We are very pleased to welcome you to City of Lisburn Athletic Club

To ensure we have the correct contact details for you, please complete this form and return to Suzie Frizzell Child Welfare Officer/Deputy Child Welfare Officer.

If you are under 18, please also ask your parent/guardian to sign the form before it is returned. The club will also use this information to ensure that you are kept informed about club events.

Dear Parent/Guardian

Anything written on this form will be held in strict confidence. Our coaches need to know these details in order to meet the specific needs of your child.

I give permission for my child to attend for training sessions and competitions (where applicable).

Child’s Full Name: _____________________________________________________

Address: _____________________________________________________________

Home Tel: _________________________ Age:______________________________

Date of Birth: ______________________ Male/Female (Please Circle)

Name of friend/relative attending: ________________________________________

Emergency telephone contact numbers

(1): ______________________________ (2): _____________________________

If unavailable contact: _________________________________________________

Tel: ______________________________ Relationship to Child: _______________

Name and Tel of G.P.: _________________________________________________

Child’s Medical Number: ________________________________________________

Details of any known special dietary requirement e.g. gluten-free diet, diabetic diet, food allergies, allergies or medical conditions

____________________________________________________________________

Any other special needs, requirements or directions that would be helpful for the athletic coaches to know about.

____________________________________________________________________

___________________________________________________________________

I will inform the coaches of any important changes to my child’s health, medication or needs and also of any changes to our address or phone numbers given.

In the event of illness, having parental/guardian responsibility for the above named child, I give permission for medical treatment to administered where considered necessary by a nominated first aider, or by suitably qualified medical practitioners. If I cannot be contacted and my child should require emergency hospital treatment, I authorise a qualified medical practitioner to provide emergency treatment or medication.

I have been made aware that the City of Lisburn athletic club has developed a child protection policy & they are committed to ensuring the safety of my child by having;

· A coaches/volunteer charter

· Clear recruitment policy which includes vetting all coaches & volunteers

· A transport policy

· A photography policy

· An anti-bulling policy

· Disciplinary procedures

· A Designated person for Safeguarding children

· Guidelines on confidentiality

The City of Lisburn athletic club is committed to ensuring that any information gathered meets the specific responsibilities as set out in the Data Protection Act 1998. The City of Lisburn athletic club will store the above information on their club data base for a maximum of 12 months before re-registering the athlete if still associated with the athletics club.

I confirm that all details are correct to the best of my knowledge and I am able to give parental/guardian consent for my child to participate in & travel to all activities. By returning this completed form, I agree to my son/daughter/child in my care taking part in the activities of the athletics club.

I understand that I will be kept informed of any activities- for example, timing and transport details.

I understand in the event of injury or illness all reasonable steps will be taken to contact me, and to deal with that injury.

I hereby give City of Lisburn athletic clubpermission to take and use any still and/or moving image being video footage, photographs and/or frames and/or video footage depicting my child, named above, when this is constant with the athletic club’s photography policy. o Yes o No

If you have ticked no, please contact us directly to enable the athletic club to try to address your specific concerns.

Signature of Parent/Guardian* ____________ ______________________________

Print Name_____________________________ Date _________________________

Signature of Child: _______________________ ______________________________

Print Name_____________________________ Date _________________________

Please return this form to the relevant Athletic Coach for your age group

* Parental consent is defined by the children (NI) Order 1995 Article 6 (i)

Natural mother always has parental responsibility.

Natural father gains parental responsibility;

If married to the mother at the time of birth or subsequently marries her
Through an agreement witnessed by solicitor or a Parental responsibility Order
Post 15 April 2002 if they jointly register the baby’s birth.