Your Details Your Date of Birth * Your Age * Your Address Postcode * Your Home Telephone Number * Your Mobile Telephone Number * Contact Email Address * How have you engaged with ITMP before? * Medical Details Please list any medical conditions that ITMP needs to be aware of, including disability or dietary requirements. * Additional Medical Consent *
During your time engaging with ITMP, if they do not bring with them medication for minor ailments such as headaches, insect bites, blisters, etc. it may be necessary for us to administer medication or plasters. Please tick to give your consent to ITMP providing you with any of the above.
I consent to visits to A&E Including any emergency dental, medical or surgical treatment as considered necessary by the medical authorities present in my best interest. * I consent to myself receiving the above necessary medical treatment for any minor injury or illness while engaging with YS. I also confirm that I will contact ITMP if there are any changes to my medical details and my emergency contact details. Parent / Guardian's Details Parent / Guardian's Name * Relationship to You Their Address * Their Postcode * Their Contact Home Telephone Number * Their Contact Mobile Telephone Number * Their Email Address Emergency Contact Details Alternative Emergency Contact * Their Relationship to the You Activity and Involvement Consent I have read, fully understood and am satisfied with the details supplied here about ITMP activities and agree to my taking part in them * Todays Date * I am happy for ITMP to take photos/films of me. * I am happy for ITMP to use photos/films of me for internal reports or reports to funders. * I am happy for IMTP to use photos/films of me for external publications (brochures, posters, leaflets. * I am happy for ITMP to use photos/films of me for web-based publicity (Website, ITMP Social Media). * I am happy for ITMP to engage Online via their virtual youth project with me through the use of Social Media platforms (Facebook, Twitter, Instagram, YouTube, Zoom etc) and our website. This will include participating with photos, video (both Live Stream and pre-recorded), posting, comments etc. Please tick as appropriate, the ways you are happy for us to communicate * I am happy for IMTP to contact me about our upcoming events, using the contact details provided above. I have read the information about Data Protection, and agree to my personal data being used in the way described above * CONFIRM INFORMATION AND SUBMIT CONSENT FORM *
By ticking ‘Yes’ above, I, confirm that all the information provided on this form is true, complete and accurate.