Princes Trust Consent Form
Activity & Medical Consent Form
To be completed by each person before taking part in any Prince’s Trust organised activity
All details will be treated in strictest confidence. Please complete all sections
During your period with the Prince’s Trust Cymru you may be participating in a range of activities which may include outdoor and adventurous activities. It is important that the centre staff are aware of all medical details.
**** PTC Contact/Signed ………………….Print…………………..…Ref No……………..
Team/Group name………Llanteg………… Course/programme name…RCA…..
Start and end Dates……….………/…………………Location………………………………………………..
Surname………………………………………. First name/s……………………………………………………
Address………………………. …………………………………………………………………………………..
Post Code …………… Tel.No ………………………Mobile……………………… Welsh Speaker Y / N
Date of birth ………/……../……… Gender Male / Female Ethnicity( Black/White/Asian etc.)….
Doctors Name / address …………………………………………………………………………………………
Parent/Guardian/Next of Kin (Name)………………………………. Address …………………………………
…………………………………………………Post Code …………….. Tel. No………………………………
Emergency contact (if different) ……………………… Address ………………………………………………
…………………………………. Post code ………………… Tel. No. ………………………………………..
Personal Medical History
Please note that it is your responsibility (parent or guardian) to notify us of any illness, disability or allergy that might affect any participation in the activities. ---à Please give details
……………………………………………………………………………………………………………………..
Special Needs Statement
Our policy is to make our activities available to all wherever possible regardless of ability. We can not however make medical assessments of an individuals special needs. We will describe the activities to you and your carer where appropriate, to the best of our ability and try our best to anticipate any additional risk that you may be running. However it is your responsibility to inform us of any special needs. If there is any doubt about your ability to safely take part in any activity, you must seek professional advice.
Additional personal details --à Please circle those that apply
Do you have qualifications? Y / N If yes please state highest qualification and level ……………………………………………….
If GCSE’s are your highest qualification: have you achieved 5 GCSE’s grades A to C including Maths and English Y / N
Do you have Sats level 5 Y / N Are you currently in education Full Time / Part time
Is your home rented/parents/yours/other……………………. Are you currently employed Full time/ Part time/ No
Are you in care Y / N Are you leaving or have you left care aged 16 and over Y / N **Heard about us from
………………………...
Are you a lone parent Y / N Do you consider yourself to have a disability Y / N
Are you currently in custody or under supervision following a court appearance Y / N
Have you been in custody or under supervision following a court appearance in the last 12 months Y / N
Have you applied for or been granted leave to remain in the UK? Y / N
Declaration
I certify that the above information is correct and I accept my responsibility for my own safety as described in the special needs statement. I authorise the Prince’s Trust to seek medical attention in the event of an emergency.
I confirm that I give my consent to the Prince’s Trust to collect and store the information disclosed to be used for statistical and fundraising purposes. I understand my right to request a copy of the information held about me by the Trust.
If you are happy for your photograph to be used by the Prince’s Trust please tick this box c
Signed …………………………….……. Print Name ………………………………..Date ………………………………
Signature of Parent/Guardian if participant is under 18 years of age.
Signed ……………………………….…..Print Name ………………………………..Date………………………………
The Prince's Trust is a registered charity no. 1079675, incorporated by Royal Charter, Head Office 18 Park Square East, London, NW1 4LH.
