2024 London AM Youth Programme 5th October 2024 – Information and Consent Form

Information and Consent form for the youth programme at “Meeting of the 7 AMs of London” on the 5th October 2024. We will be joined by young people in London for Meetings for Suffering.

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2024 London AM Youth Programme 5th October 2024 – Information and Consent Form
at Friends House London for those born between 31.08.2006 and 31.08.2013
Completing the form
Please read the guidance and complete the form as requested.
This Information and Consent form must be completed for all those participating in BYM events for Children & Young People. This form covers information required for insurance purposes (as BYM and its staff are responsible for the care and safety of participants) This also enables the effective planning and running of events taking into account the particular needs of those attending.
This form will be handled, and the data will be stored, in electronic and paper forms in accordance with BYM Polices.
All participants need to agree to abide by the stated community agreement during the event, and accept responsibility for the consequences of any breaking of this community agreement (which may include being asked to leave the event). There is space for the participant to indicate their agreement to this in section 8 of the form.
Criteria under which you are completing the form * REQUIRED
As the participant is aged 17 or under the form should be completed by a parent/guardian.
In the case of foster carers, the consent sections should be signed by the person with parental responsibility (you should also provide their contact details in the section about children and young people in care). In section 3 (emergency contacts) there is space to indicate if the participant is a ward of court or a ‘looked after child’.
1) About the Participant
Participant's Legal Name * REQUIRED
For example, the one used on their medical records
First Last
Participant's preferred name * REQUIRED
The first name the participant would like to be known by at the event.
Participant's Address * REQUIRED
Street Address City Region Post code Country
Participant's phone number (landline)
Participant's phone number (mobile)
Participant's email
One that is checked regularly
Please provide the participants email. This will be used to contact them by mail chimp (if permission is given) and for direct email communication.
There is space later on the form to provide your own email address.
Participant's Date of Birth * REQUIRED
(must be after 31.8.2006)

Day
Month
Year
Participant's gender identity * REQUIRED
Please state pronouns used
Participant's Quaker Community

3) Emergency contacts
This information enables us to contact those who need informing in the event of an emergency.

Please provide contact details for two individuals
The first person should be the person who has parental responsibility or guardianship of the participant.
The second person should – where possible – be at an alternative address to the first contact.
First emergency contact * REQUIRED
This should be the person with parental responsibility or guardianship of the participant.
First Last
First emergency contact: Relationship to the participant * REQUIRED
Children and young people in care
If the participant is a ‘looked after child’ or ‘ward of court’ please tick the relevant boxes.
- Looked after child
- Ward of court
In care details * REQUIRED
If the participant is a ‘looked after child’ or ‘ward of court’ please provide relevant details.
First emergency contact: Address during the event * REQUIRED
Street Address City Post code Country
First emergency contact: Phone number (landline) * REQUIRED
First emergency contact: Phone number (mobile) * REQUIRED
First emergency contact: Email (one that is checked regularly) * REQUIRED
Secondary emergency contact * REQUIRED
We require a second emergency contact in the event that we are unable to make contact with the person with parental responsibility or guardianship.
It is preferable that this person is a a different address to the emergency contact stated above.
First Last
Secondary emergency contact: Relationship to the participant * REQUIRED
Secondary emergency contact: Address during the event * REQUIRED
Street Address City Region Postcode Country
Secondary emergency contact: Phone number (landline) * REQUIRED
Secondary emergency contact: Phone number (mobile) * REQUIRED

4) Participant needs
This helps us plan for or be aware of any needs the participant may have and how this might affect the support we provide and our facilitation at the event. You may find it helpful to read the following:
Why we ask about participant needs explains why we ask for this information.

With health conditions this means that if the participant is taken ill we have the appropriate information to hand to health care professionals.
Please indicate if the participant has any of the following:
Asthma * REQUIRED
Asthma emergency * REQUIRED
If relevant, please detail actions to take in an emergency

Please describe what signs or symptoms indicate an asthma attack for the participant.
Please state what signs and symptoms indicate an asthma attack. Please also include any information that we might need to know (for example admitted to hospital in the last year for asthma, the type of inhalers they use) Action in an emergency (edit as appropriate) 1) Sit participant up straight – try to keep them calm 2) Encourage them to take one puff of their reliever inhaler (usually blue) every 30-60 seconds up to 10 puffs. 3) If they feel worse at any point OR they don't feel better after 10 puffs call 999 for an ambulance. 4) Repeat step 2 after 15 minutes while you are waiting for an ambulance. IMPORTANT! Not applicable to SMART or MART medicine regimes. If this is the case please provide accurate information.
a) Allergies (including anaphylaxis) * REQUIRED
e.g. dietary, medication, chemical, environmental etc
a) Allergies emergency
If relevant, please detail actions to take in an emergency (in relation to allergies)
In the event of a medical emergency:
Please describe what signs or symptoms indicate an emergency for the participant.
Please detail the action to be taken in the event of an emergency,
• if and how medication should be administered and the amount
• any special precautions in relation to the medication that should be taken, e.g. signs that medication should not be given, any side effects that we need to know about
• the procedures we should take in an emergency
• include anything medical professionals need to know
• besides yourself, who should be notified, e.g. specialists, GP.
a) Allergies detail * REQUIRED
Please give further details to enable us to appropriately support the participant.
• explain how it affects the participant (e.g. regularity, impact).
• if they have needed emergency treatment or have been admitted to hospital in the last year.
• if relevant how it can be avoided, prevented or minimised.
• detail any action we may need to take for example if there are any support needs (in the box below please detail how we should respond in an emergency).
• if relevant give the contact details for medical professionals or social worker.
b) Cognition and learning needs * REQUIRED
(e.g. Dyslexia, ADHD, Dyspraxia etc)
b) Cognition and learning needs detail * REQUIRED
Please give further details to enable us to appropriately support the participant.
• what are the characteristics of their need
• what type of situations do they find particularly difficult?
• what might indicate that they are struggling or finding something challenging?
• what strategies help them to manage their need?
• are there any adjustments that would further their participation?
• to what extent does their need impact on their life i.e. do they have additional support provided e.g. extra help in school, specialist support, a statement of SEN, an EHC plan (what does this recommend)? What support do they require to further participation?
• if relevant and appropriate give the contact details for supporting professionals.
c) Communication and interaction needs * REQUIRED
(e.g. Autistic spectrum condition, support from a speech and language therapist, hearing impairment etc)
c) Communication and interaction needs detail * REQUIRED
Please give further details to enable us to appropriately support the participant.
• what are the characteristics of their need?
• what type of situations do they find particularly difficult?
• what might indicate that they are struggling or finding something challenging?
• what strategies help them to manage their need?
• are there any adjustments that would further their participation?
• to what extent does their need impact on their life i.e. do they have additional support provided e.g. extra help in school, specialist support, a statement of SEN, an EHC plan (what does this recommend)?
• what support do they require to further participation?
• if relevant and appropriate give the contact details for supporting professionals.
d) Mental health conditions * REQUIRED
(e.g. panic attacks, depression, self harm, disordered eating etc)
d) Mental health conditions detail * REQUIRED
Please give further details to enable us to appropriately support the participant.
• what are the characteristics of their need
• what type of situations do they find particularly difficult?
• what might indicate that they are struggling or finding something challenging?
• what strategies help them to manage their need?
• are there any adjustments that would further their participation?
• to what extent does their need impact on their life (how regularly does it have an impact, what impact does it have)?
• if relevant and appropriate give the contact details for supporting professionals
e) Physical health conditions * REQUIRED
(e.g. Asthma, Diabetes, Epilepsy, Migraine, Hyper-mobility Syndrome etc)
e) Physical health conditions emergency
If relevant, please detail actions to take in an emergency (in relation to physical health conditions)
e) Physical health conditions detail * REQUIRED
Please give further details to enable us to appropriately support the participant.
• explain how it affects the participant (e.g. regularity, impact,)
• if they have needed emergency treatment or have been admitted to hospital in the last year
• if relevant how it can be avoided, prevented or minimised
• detail any action we may need to take (how we should respond in an emergency, and if there are any support needs)
• if relevant give the contact details for medical professionals or social worker
f) Sensory and physical needs * REQUIRED
(e.g. impaired hearing, impaired sight, colour blindness, restricted mobility etc)
Sensory and physical needs details * REQUIRED
Please give further details to enable us to appropriately support the participant.
• what are the characteristics of their need
• are there particular situations that they find particularly difficult?
• what might indicate that they are struggling or finding something challenging?
• what strategies help them to manage their need?
• are there any adjustments that would further their participation?
• to what extent does their need impact on their life (e.g. what impact does it have)?
• if relevant and appropriate give the contact details for supporting professionals
g) Social and/or emotional wellbeing * REQUIRED
e.g. young carer, third culture individual, low self esteem, or anything else we should be aware of to ensure the participant has appropriate support at the event
g) Social and/or emotional needs detail * REQUIRED
Please give further details to enable us to appropriately support the participant.
• what are the characteristics of their need
• what type of situations do they find particularly difficult?
• what might indicate that they are struggling or finding something challenging?
• what strategies help them to manage their need?
• are there any adjustments that would further their participation?
• to what extent does their need impact on their life (how regularly does it have an impact, what impact does it have)?
• if relevant and appropriate give the contact details for supporting professionals
h) Medical treatment * REQUIRED
Does any of the above (a-g) require medical treatment
h) Information about medication
If relevant please include the following information about the medication:
• the medication required and the condition it is for
• the amount taken and how the medication is taken e.g. tablets, inhaler, injection
• when the medication is taken (times of day, in an emergency)
• whether the participant can self medicate
• any side effects resulting from the medication that we need to know about
• any storage requirements for this medication (e.g. refrigeration, secure for a controlled drug). Please ensure that medication is sufficient and is clearly and correctly labelled, i.e. that it is in the correct container, with participant’s details, and indicates the dose taken each day.
h) Medication in an emergency * REQUIRED
The participant can be administered their medication by an adult team member in an emergency
i) Able to participate * REQUIRED
I consider the participant to be medically and psychologically fit to participate in this event
- Yes

5) Medical information
It is your responsibility to notify us, in advance of the event, of any changes in the medical information or medical treatment detailed on the enclosed form.
Any updates should be written, signed and sent to bymeevents@quaker.org.uk
You must also contact us if the participant is exposed to, or suffers from any infectious disease in the 4 weeks prior to the event. Informing us of this will not necessarily preclude them from attending the event. Decisions would be made on a case by case basis and in light of any vulnerable participants or team members who may be adversely affected by the infection.
Name of GP
First Last
Surgery Phone Number * REQUIRED
Surgery Address * REQUIRED
Surgery Name Street Address City Region Postcode Country
Date of last anti-tetanus injection (if known)

Day
Month
Year
Medical permissions
Pain/Flu relief – the provision of pain/flu relief is not a service Britain Yearly Meeting events are obliged to undertake. We recognise that whist at events, participants can become unwell so ask that you indicate your consent or otherwise to pain/flu relief medication that may be given.
Ibuprofen * REQUIRED
Paracetamol * REQUIRED
Flu relief * REQUIRED
Plasters * REQUIRED
Plasters detail
Please provide detail (e.g. no plasters, no waterproof plasters, no latex, micropore ok etc)
Sting relief * REQUIRED
Sun cream * REQUIRED
We provide factor 30
Infectious disease measures * REQUIRED
If the participant becomes unwell at the event are you able to arrange private transport from the venue?
- Yes
- No
In the event of an emergency or accident.
Should your child/ward become ill or have an accident, every effort will be made to contact you as soon as possible.
In the event of an emergency or accident we will call the emergency services first. Healthcare professionals may give treatment immediately when it is in the young person’s best interests.
For them to attend the event, you must give the following permission:
Emergency treatment * REQUIRED
I give permission for any treatment deemed necessary and in the young person’s best interests to be given by healthcare professionals. If you do not give permission your child cannot attend the event.
- Yes

6) Data protection
Use of data
In accordance with the UK Data Protection legislation and EU General Data Protection Regulation, permission must be granted by the parent/guardians or participant (if over 18) before any images may be taken and used, and for how the personal data can be used.

Quakers in Britain uses photography to attract new members, encourage people to take part in our activities and contribute to our funds.

Please indicate whether you give your consent for images of your child/ward to be used for these purposes in all of the following: print, website, e-books, other electronic formats and social media (Facebook, Twitter, etc.).
We do not identify people by name or meeting without specific, prior permission. We will not identify children and young people under the age of 18 by name, local meeting or where they live.
Some images or recordings may be kept permanently once they are published and archived by the organisation.

We may use images on collaborative work with other organisations e.g. Woodbrooke.

These will be the copyright of Britain Yearly Meeting (the legal name for Quakers in Britain), and any other intellectual property which arises in the recordings will also belong to Britain Yearly Meeting.
I can ask Quakers in Britain to stop using my images at any time, in which case they will not be used in future publications but may continue to appear in publications already in circulation (contact BYM Data Safety Group to discuss at datasafety@quaker.org.uk)
I can complain about the use of my image/audio by contacting Quakers in Britain Data Safety Group at datasafety@quaker.org.uk
Image consent * REQUIRED
Do you actively consent to the participant’s image being used under the above conditions?
Should you wish to withdraw your consent at any time, please contact: bymevents@quaker.org.uk
Picture * REQUIRED
We need a record of what the participant looks like, this enables us to delete any images taken of them during the event.
Please upload a picture of the participant
Max. file size: 2 MB.
Data consent * REQUIRED
Do you actively consent to the contact information you have provided being used to send promotional information about future events and opportunities?
Should you wish to withdraw your consent at any time, please contact: bymevents@quaker.org.uk
Online communications
BYM staff use social media and mail chimp to communicate with young people about the event and ways they can be involved in opportunities within Quakerism and young people’s organisations:
Mailchimp * REQUIRED
Do you actively consent to our using the above data to make contact using mailchimp?
Should you wish to withdraw your consent at any time, please contact: bymevents@quaker.org.uk
In agreeing to this you acknowledge that the information you provide will be transferred to MailChimp for processing in accordance with their privacy policy and terms.
Social media * REQUIRED
Do you actively consent to us contacting the participant using BYM social media accounts: Facebook, Instagram and Twitter.
We will only contact children over the age of 13 using social media.
Should you wish to withdraw your consent at any time, please contact: bymevents@quaker.org.uk

Event Consents
Please read and indicate your consent below:
I give permission for the named participant to take part in this event.
I understand that there will be consequences if the participant breaks event boundaries – the most serious of which is to be asked to leave the event (if this happened the person with parental responsibility would be contacted).
I understand that if my child/ward has particular needs and I haven’t included this information on the form, or subsequently informed the staff in writing and this has a detrimental impact on the programme or other participants, Britain Yearly Meeting may have to withdraw them from the programme.
I understand that the Children Act (2004) requires that if a team member is concerned about the safety of a participant (or the safety of someone known to them) they are required to inform the event’s Safeguarding Coordinator.
I understand where relevant the information on this form will be shared with the venue, and if necessary with healthcare professionals.
Community agreement * REQUIRED
I understand that the participant’s place is conditional on them signing up to the event community agreement.
Sexual health, sexuality and gender identity * REQUIRED
I consent to my child/ ward’s participation in any optional sessions provided that cover sexuality and gender identity, sexual health consent and contraception.

Yes

No
Signature and event consents * REQUIRED
To be completed by the parent/ over 18 participant/ or legal guardian or social worker.
I have read the guidance and information on this form and have completed all relevant sections accurately and in full. I give my consent to the statements and requirements on this form and for the named participant to attend as stated. If you would like any further information or have any questions about any part of this form please contact
Julia Stacey (London Children & Youth Dev Worker) on julias@quaker.org.uk.
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2024 London AM Youth Programme 5th October 2024 – Information and Consent Form