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creating and maintaining safe environments
guidance for indicator 1.4

1.4A Template 3: Child and Guardian Joint Consent

1.0 Data protection

This form will be held on file, in accordance with the data protection policy of
 	(insert name of Church body). The data entered will be used only for the purpose indicated on the form. It may only be accessed by those with responsibility for managing records or group activities.

2.0 Group details (to be completed by organiser)

Name of group

Duration/frequency of activity from (start date/time)

(end date/time)

Name of organiser  	

3.0 Details of the child/young person

Name of young person   	

Address  	

Date of birth  	

Gender (circle as appropriate)	Male	Female

4.0 Other relevant information

(Please mention any medical conditions, special needs or dietary requirements).

Please note that the organisers cannotadministeranymedication. Should your child require medication or intimate care, please discuss this with the organisers who will work with you to establish how your child can be accommodated, according to relevant policies and procedures.

5.0 Guardian contact details

Name  	

Daytime phone number	Code 	

Local no.  	

Home phone number	Code 	

Local no.  	

Mobile number 	

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crEating and maintaining saFE EnvironmEnts
guidance for indicator 1.4

Email  	

Contact information for emergency use only (if different from the information given above)

6.0 In cases of a medical emergency

In the event of illness or an accident, I give permission for medical treatment to be administered to my child, where considered necessary, by a suitably qualified medical practitioner and/or hospital. I understand that every effort will be made to contact me as soon as possible. In an emergency I can be contacted at the telephone numbers provided on the previous page:

Signed 	

7.0 Child’s/young person’s consent

I	(insert full name) would like to take part in the event listed on the previous page.

(If relevant please tick the boxes below)

•	I understand that photographs may be taken during the group activities, and I give my permission for these to be used in any hard copy/online (delete as appropriate) publications by the	(insert name of Church body).

•	I understand that videos (which may include webcam) may be taken during the group activities, and I give my permission for these to be used in any hard copy/online (delete as appropriate) publications by the	(insert name of Church body).

•	I understand that during group activities I will be appropriately supervised at all times and will agree to abide by the group’s code of behaviour.

8.0 Guardian’s consent

I agree to allow the above-named child/young person to attend meeting(s) of the  	 (insert name of group), at the times and dates stipulated in section 2.0 in accordance with the permission granted by	(insert name of child/young person) above. I understand that there will be suitable supervision and an agreed code of behaviour while the children/young people are in the care of the organisers.

Signed  	

Name (block letters)  	

(Guardian)	(Guardian)

Relationship to child/young person  	

Signed  	

(Child/young person)