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The ReConnect Programme Ltd

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Emergency contact & consent FORM

For assistance to complete this form or for more information please contact:

admin@reconnect1-1.com

07599 035520

emergency contact & consent form

Young Person's Details

Young Person's First name*

Young Person's Last name*

Gender

Birthday*

Day

Month

Year

Ethnicity

Religion

Language

Young Person's Home Address*

How will your young person be transported to and from The ReConnect Programme?*

Young Person's Emergency Contact Details

Parent/Guardian Name (Primary contact)*

Parent/Guardian Mobile Number (Primary contact)*

Parent/Guardian Home Number (Primary contact)

Parent/Guardian Home Address (If different from YP)

Parent/Guardian Email Address (Primary contact)*

Parent/Guardian Work Name

Parent/Guardian Work Address

Parent/Guardian Work Number

First Emergency Contact Name (Different to primary contact)*

Relationship to Young Person (Different to primary contact)*

First Emergency Contact Number (Different to primary contact)*

Secondary Emergency Contact Name

Relationship to Young Person

Secondary Emergency Contact Number

Social Worker Name (If applicable)

Social Worker Number (If applicable)

Any other important contact details for the young person:

Any other important contact details for the young person and their relationship to them:

Medical

Medical Conditions Please tick this box if the participant has any medical conditions we should be aware of, and provide details below of diagnosis and medication:

Medical Conditions Information*

Medication requirement Information*

Young Person's Doctor Name*

Surgery Address*

Surgery Phone Number*

Dietary Requirements

Allergies Please tick this box if the participant has any allergies we should be aware of, and provide details below:

Allergy Information*

Has your Young Person's Allergy been diagnosed by a Health Care Professional?

Does your Young Person have an Allergy Management Plan from their Health Care Professional?

Describe the symptoms of an allergic reaction. Give as much detail as possible

Has your Young Person been prescribed any medication related to their allergy?

Please give details of any emergency procedures

Does your young person have any dietary requirements?

Consent Forms

Please tick boxes to give your permission:

Photography & Video (External Use)

I give permission for my young person’s image and/or video to be used in promotional materials such as brochures, posters, websites, and social media for The ReConnect Programme.

Photography & Video (Internal Use Only)

I give permission for my young person’s image and/or video to be captured and used for internal records and learning portfolios (not shared publicly).

General Construction Activities

I give permission for my young person to take part in supervised construction-related activities, including the use of hand tools, woodwork, and basic DIY projects.

Jump Biking & Skate Park Activities

I give permission for my young person to participate in jump biking activities, which may include using ramps and trails, under supervision and with appropriate safety equipment.

Sports & Fitness (including Weights and Calisthenics)

I give permission for my young person to engage in physical activities including team sports, personal fitness sessions, weight training, and calisthenics.

Off-site Activities

I give permission for my young person to attend off-site trips and activities as part of their programme, which may include visits to parks, sports venues, or other educational locations.

Transport between ReConnect venues

I give permission for my young person to be transported by The ReConnect Programme staff in a car, minibus, or other approved transport to and from sessions or venues.

Leaving Unattended

I give permission for my young person to leave The ReConnect Programme site on their own at the end of the school day.

Administer First Aid

I give permission for my young person to receive first aid treatment when in the care of The ReConnect Programme.

Contacting Doctor surgery

I give The ReConnect Programme permission to contact my Young Person's doctor surgery.

Waiver & Acknowledgement

I acknowledge that whilst all activities will be carried out with appropriate risk assessments, trained staff, and necessary safety precautions, there are inherent risks in some activities. I agree not to hold The ReConnect Programme, its staff, or affiliated partners liable for any injury, loss, or damage that may occur during participation, except in cases of proven negligence.

I confirm that all information provided is accurate and up to date, and I understand I may withdraw consent for any of the above at any time by notifying the programme in writing.

Signature

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Date*

Day

Month

Year

Contact

Email: admin@reconnect1-1.com

Phone: 07599 035520

12 Looms Lane,

Bury St Edmunds,

IP33 1HE

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The ReConnect Programme Ltd

Registered Office: Unit 27 Thurston Granary Station Hill, Thurston, Bury St. Edmunds, England, IP31 3QU

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