Child`s emergency contact and medical information

Young Persons Information Form
Young Person’s Details
M
Child’s Name
Date of Birth
Sex
Address of child
Town
Postcode
Ethnicity (Leave blank if prefer not to say)
Religion
Name child is known as (If different from above)
Parents/ Guardians Contact details
Main Parent/Guardian name
Additional Parent / Guardian name
Address
Address (If different from main Parent/Guardian )
Town/Postcode
Town/Postcode
Contact number 1
Contact number 1
Contact number 2
Contact number 2
Email Address
Email Address
Relationship to child
Relationship to child
Additional Emergency contact details
Name of additional contact
Relationship
Address
Town/Postcode
Contact number 1
Contact number 2
Medical Information
Doctors Surgery
Doctors Name
Phone Number
F
Young Persons Information Form
Has your child any allergies, medical conditions, dietary requirements, special needs, behavioral problems or any other
conditions, behaviors, problems or issues that we should know about? Please give as much detail as you can below.
Please use an additional sheet if more room is required
Other Information
Can your child swim 50M?
Can your child stay afloat for 5min in light clothing
Photo Permission
In the course of your child’s involvement with 1st Halton it is likely that they will take part in activities where the press and the other
members of the Scout Association will be taking photographs. These will be used for purposes such as the promotion of the Scout
association or 1st Halton Scout group (such as our website, newsletter, slideshow or poster).
At camps and during activities run by the group, district or County we like to photograph the members enjoying the activity, giving them
the opportunity to reflect on what they have achieved.
In line with the data protection act we are required to ask you to complete the following:
Please tick the box as appropriate:
st
 I agree to the person named above to be involved in photographs/videos during activities run by the 1 Halton Scout
Group or the Scout association.
st
 I do not agree to the person named above to be involved in photographs/videos during activities run by the 1 Halton
Scout Group or the Scout Association.
I have explained to the person named above that I have requested that they are excluded from any
photographs/videos that may be taken.
Data Protection
Any information supplied will be treated with confidence and respect and will only be used for the purpose of Scouting.
Please complete the form in full and delete the incorrect statement below.
I herby do / do not give permission to the following:
That 1st Halton Scout Group may retain information provided to them in respect of the child’s membership to 1st Halton Scout Group and
the Scout association. Personal data will be stored on a paper and electronic system to support the application process and current and
potential future involvement in Scouting. Some information is considered sensitive personal data under the Data Protection Act 1998 and
as such will be managed as required under the act. Further information can be found at scouts.org.uk/dataprotection.
That 1st Halton Scout Group hold information in relation to the member’s health, disabilities, behavioural problems, religion, faith, race,
ethnic origin and any other information that may be relevant. This information you are being asked to provide is requested by The Scout
Association to help in monitoring its membership. The data will help the Association in understanding the makeup of the membership;
monitoring progress against its inclusivity objective, and prioritising development work both nationally and locally, and will identify and
help Leaders meet any specific needs of individuals.
Any of the information supplied will be passed to the Scout association as and when requested.
Young Persons Information Form
Data Protection
As a registered Data Controller, The Scout Association is committed to the Data Principles of the Data Protection Act 1998.
By signing this form, I agree to the Scout Association during and beyond my child’s involvement with the organisation:
a) Retaining personal data to facilitate any present or potential future involvement with Scouting;
b) Retaining personal data regarding religion, special needs/disabilities, ethnicity, medical information and/or commission of offences or
alleged offences
c) Allowing access to personal data to appropriate individuals within the hierarchy of Scouting.
Declaration
I have read and agree with the policies as outlined in the welcome pack.
I have read the photo declaration and ticked the appropriate box.
I have read the Data Protection Statement and deleted the incorrect statement.
If it becomes necessary for the above named young person to receive medical treatment and I cannot be contacted to authorise this, I
hereby give my general consent to any necessary medical treatment and authorise the Leader in charge to sign any document required
by the hospital authorities.
I declare that the information provided is correct at the time of completion of this form; however I accept responsibility to advise you of
any changes to the above.
Signed
Printed name and relationship
Date
Leaders Use
Gift Aid Yes/No
Section YP is starting in
Photo Permission Yes/No
Form returned date
Start date
Delete as appropriate
Compass Updated Yes/No
OSM Updated Yes/No
GA to Treasurer Yes/No
Delete as appropriate
Delete as appropriate
Signed
Name and Section
Date
Standing Order Yes/No
Delete as appropriate
Data Protection Yes/No
SO to Treasurer Yes/No