Zephyr Blofeld

YCF West Participant Consent Form Spiceland Residential 3-4 May 2024

A one time form that covers a child or young person's participation for the residential at Spiceland Meeting House Camp 3-4 May 2024.

Step 1 of 7

Consent and information form
Please complete the form as requested. If the participant is aged 17 or under, the form should be completed by a parent/guardian. 18 year old participants complete it themselves.
1) About the Participant
Participant's Name * REQUIRED
First Last
Participant preferred name * REQUIRED
Name the participant would like to be known by at the event
Participant Address * REQUIRED
Street Address City Post code Country
Participant's phone number (landline)
Participant's phone number (mobile)
Participant's Date of Birth * REQUIRED

Day
Month
Year
Participant's age * REQUIRED
Participants natal sex * REQUIRED
Please state
Participant's gender
Please state.
Participant's ethnicity

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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.
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First emergency contact: Relationship to the participant * REQUIRED
If the participant is not under the care of their parent or guardian (a 'looked after child or a 'ward of court') please tick below
If the participant is not under the care of their parent or guardian (a 'looked after child or a 'ward of court') please tick below
First emergency contact: Address during the event * REQUIRED
Street Address City Post code Country
First emergency contact: Phone number (landline)
First emergency contact: Phone number (mobile) * REQUIRED
First emergency contact: Email (one that is checked regularly) * REQUIRED
Secondary emergency contact * REQUIRED
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Secondary emergency contact: Relationship to the participant * REQUIRED
Secondary emergency contact: Address during the event * REQUIRED
Street Address City Postcode Country
Secondary emergency contact: Phone number (landline)
Secondary emergency contact: Phone number (mobile) * REQUIRED

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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.
Please indicate if the participant has any of the following:
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 disorder, 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 or 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 health * 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) Medication in an emergency * REQUIRED
The participant can be administered their medication by an adult team member in an emergency

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Event Consents
Please read and indicate your consent below:
- I give permission for the named participant to take part in this event organised by the West Youth Development Worker
- 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.
Outward bound activities * REQUIRED
I give permission for my child/ward to participate in any outward bound activities that may be offered on the programme.
- 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
Zephyr Blofeld zephyrb@quaker.org.uk.
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Author: Zephyr Blofeld

Spiceland Residential Camp 4th-5th May Booking Form

YCF West Participant Consent Form Spiceland Residential 3-4 May 2024

Step 1 of 7

Consent and information form

1) About the Participant

2) Participant's dietary information

3) Emergency contacts

4) Participant needs

Please indicate if the participant has any of the following:

Medical permissions

In the event of an emergency or accident.

6) Data protection

Use of data

Event Consents

Finally in 3D! Participants feedback form

Finally in 3D! Volunteer Feedback