Yorkshire Consent and Information form

2023 YCF QIY Yorkshire Link Group Activities Consent & Information form

A one time form that covers a child or young person for various Yorkshire Quaker Link Group events. Once filled in you don't need to repeat this form for the next event unless something changes. You will be required to tick a box before a proceeding event saying "my child's consent and information form is upto date" if you are rolling over information and consents.

Step 1 of 7

Consent and information form
Please complete the form as requested.
This form must be completed for all those participating in our events. 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 email * REQUIRED
One that is checked regularly
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
Does your child/ward go to a Quaker Meeting? * REQUIRED
- Yes
- No
Name of participant's Local Meeting * REQUIRED
Name of participant's Area Meeting * REQUIRED

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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.
First Last
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
First Last
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
i) Able to participate * REQUIRED
I consider the participant to be medically and psychologically fit to participate in this event
- Yes

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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 Jo Baynham jonathonb@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
Street Address City Postcode Country
Medical permissions
Pain/Flu relief - the provision of pain/flu relief is not a service Britain Yearly Meeting events are obliged to undertake, so we ask you indicate your consent or otherwise to 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
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:
I give permission for any treatment deemed necessary and in the young person's best interests to be given by healthcare professionals. * REQUIRED
- Yes

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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.
- 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 my child/ward 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.
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
Jo Baynham jonathonb@quaker.org.uk.
First Last

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Yorkshire Consent and Information form

2023 YCF QIY Yorkshire Link Group Activities Consent & Information form

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:

5) Medical information

Medical permissions

In the event of an emergency or accident.

6) Data protection

Use of data

Event Consents