Register for the Achieve Programme
Registration / Parental Consent Form – The Game Change Project
Referred By (Required):
Referrers Email (Required):
Organisation (Required):
School Attended (Required):
Involvement with other agencies (social services, CAMHS etc)?
Please note that the information on this form is for the use of the Game Change Project for the purposes of providing our services to your child and will be treated as confidential (unless we need to comply with a legal obligation).
Details of Young Person
First Name (Required)
Surname (Required)
Date Of Birth
Address
Line 1:
Line 2:
Town:
County:
Postcode:
Telephone:
Sex / Gender:
Emergency / Parental Contact Details
In the event of an emergency relating to the participant please provide information below which we can use to contact you.
Adult Emergency Contact Name (Required)
Relationship
Contact Telephone Number/s (Required)
Email Address
Home address (if different from above):
Alternative Emergency Contact Name:
Relationship
Contact Telephone Number/s
Medical Information
Are there any medical conditions (i.e. allergies, epilepsy, asthma, diabetes, travel sickness etc.) or disabilities which we should be aware of?
Diet
Please give any details of special dietary needs we should be aware of (e.g. food
allergies, intolerances, religious requirements):
Behaviour
Please give details of any behavioural/emotional needs we should be aware
of and how we can best support your child or young person:
Historic Behaviour
Please indicate if the young person has a history of any of the following *inappropriate sexualized behaviour *self-harm *violence or abuse of animals *absconding
Activities
Please check which modules are of interest and indicate level of experience (if any):
Experience Level:
Experience Level:
Experience Level:
Marketing
We may take photographs and videos of activities. These images may be used on social media or for promotional purposes.
If you do NOT wish for your son/daughter to be photographed please tick this box:
(Participants can opt out of photographs and names/other identifiable information will not be published without content.)
Code of Conduct
Please tick to confirm that the young person has understood and agreed to follow the Code of Conduct for participants.
Terms and Conditions
Please tick to confirm that you agree to the terms and conditions.
Policies
You can find our safeguarding policy, complaints and compliments, whistleblowing and health and safety policies by following this link (Opens in a new window):
Consent
I agree to my son/daughter participating in The Game Change Project and the activities run by the team. I understand that every care will be taken to ensure the health, safety, and welfare of my child. I accept and support the code of conduct for behaviour. I support the “no use of mobile phones on site policy” and understand that staff can be contacted in the event of an emergency. I realise and accept that in the event of my child’s behaviour adversely affecting the safety of the activity, the organisers reserve the right to require me or any of the emergency contacts to collect return my child home with immediate effect.
I agree to be contacted by (please tick): E-mail: or Telephone: regarding my son or daughters progress on this course.
Confirm you are not a ROBOT
Type the letters shown below in the panel and press the Register Now button.