Pre Registration Form

Gosport Summer Passport 2017

PARTICIPANT INFORMATION






MaleFemale





PARTICIPANT MONITORING INFORMATION:
Ethnicity:
A. White
English/Welsh/Scottish/Northern Irish/BritishIrishGypsy or Irish TravellerAny other White background, write in
B. Mixed/Multiple Ethnic Groups
White and Black CaribbeanWhite and Black AfricanWhite and AsianAny Other Mixed/Multiple Ethnic background, write in
C. Asian/Asian British
IndianPakistaniBangladeshiChinese


D. Black/African/Caribbean/Black British
CaribbeanOther Black/African/CaribbeanBangladeshiChinese

E. Other Ethnic Group
ArabOther Ethnic Group

Disability
NoYes

LearningHearingVisualPhysicalMultipleMental Health

PHOTO CONSENT:

Partner of the Gosport Summer of the Passport Scheme May like to take photographs of your child.Please tick the box below the give Permission for photographs to be taken. This photo may be used in publications or on the safer Gosport website/Facebook site.

I give permission for my child to be photographed by partner and for all the photo to published to promote the Gosport summer passport SchemeI do not give permission for my child to be photographed
PARENT OR PERSON WITH PARENTAL RESPONSIBILITY CONSENT SIGNATURE:

I have read and understood the information provided and give permission for the person named to participate in the Gosport Summer passport Scheme from the 1st August to the 17th August 2017 inclusive. I understand that they have responsibility to behave appropriately and that if they do not adhere to the behaviour code, they will be excluded or further action will be taken. In the event of a medical emergency I give my consent for all necessary treatment. I confirm that I am the Parent/person with parental responsibility of the child name.

Please tick if your child has participated in the Scheme previously




None of the information in this form will be provided to any other organization in compliance with the data protection Act 1988. Registration must be completed every year, with permission valid for two years from the date of signing

Please unsure that you inform us should any of the participant’s details stated on this form change at any time and which may impact upon their participation (such as changes in health or behaviour).

Please make sure your child attends appropriately dressed for the activities and bring their own food, drink and sun protection.

Partners from the Gosport Summer Passport scheme reserve the right to request proof of age, failure to produce suitable documentation such as Passport or Birth Certificate, may result in your child being unable to participate.

Please see the Gosport Summer Passport leaflet for more information about the activities and contact details.Further details on scheme and guidelines can be found on