"*" indicates required fields Date of Arrival*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent / Carer detailsParent / Carer name*Contact number*Email address* Address* Street Address Address Line 2 City County Post Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Child / Young person detailsName of child / young person* First name Last name Likes to be known as The child / young person resides at the address listed above* Yes No Address* Street Address Address Line 2 City County Post Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands GenderSchool Year in September 2024*Date of Birth*Age on Arrival*Medical information/AllergiesHas your child ever suffered from any of the following?* My child does not have any medical conditions Epilepsy Cardiac or Respiratory problems Latex Allergy Asthma Migraines Diabetes Plaster Allergy Food Allergy Other If yes please give detailsIs your child currently taking any medication?Please tick all that apply* My child is not currently taking any medication Insulin Epi Pen Inhaler Other If you have answered yes to any of the above, please give detailsPlease tick to agree to the following statementsI understand that it is the responsibility of the parent / carer to administer any medication during the sessions.* Yes I understand that I will be contacted if an accident should occur that requires more than basic first aid.* Yes I am aware that a parent, carer or another named adult must remain on site for the duration of the creche, youth & children's sessions. Also, no young people under the age of 18 may be left on site unsupervised at any time.* Yes If you cannot contact me directly in an emergency, I give full permission for my child or young person to receive treatment administered by a doctor, dentist, paramedic or other qualified person.* Yes No Additional NeedsPlease contact the Youth Team on 01756 760500 if you would like to discuss your child, or young person’s needs directly.Does your child or young person have any additional needs including physical, learning difficulty, or a recent life change (including bereavement, separation, adoption etc) that we need to be aware of?* Yes No In order to best meet the individual needs of a child or young person you are bringing to Scargill House, we would find it really helpful if you could discuss any additional needs a child has before visiting. Please do let us know in advance of any other specific needs that might help your child’s stay be more comfortable. That way the team can work together with you to see how we can include all children in what Scargill has to offer. We are committed to finding ways to make it work on a case by case basis. Unfortunately, we are unable to offer one to one care for any individual child. On occasions it may be necessary for an adult from your party to attend the youth and children’s sessions with a child that has additional needs. We know that being a full time carer for a child with additional needs can be tiring, so please feel free to speak to us about funding to bring an extra adult along to help out.If yes to the above please could you give further information here.Appropriate ClothingPlease ensure that your child comes to sessions in clothing that could be worn outside – especially footwear. We will inform you in advance if we are planning to go up onto the estate, in which case, long trousers, suitable footwear and a waterproof coat are recommended. If your child requires sun cream or insect repellent please ensure you apply this before each session.A Creche will run for one hour during the first adult session. This is for children who have not yet started Primary School.Early years information (Complete for children under 5) My child wears a nappy My child is potty training I give permission for a member of the Scargill Youth Team to change my child’s nappy, or to assist with toileting I would prefer if you came & found me to deal with any of my child’s toilet needs Collection at the end of each sessionI understand that, if my children have not yet started secondary school, it is my responsibility to bring them to sessions and meet them in the Sun Lounge at the end of each session (at the time indicated on the programme)* Yes My child is in Secondary school, and I am happy for them to leave at the end of each session, without being collected by an adult. Yes No Out of Session ResponsibilitiesCreche runs 10.15-11.15, and the youth & children's sessions (5 – 17 yrs) from 10.00 – 11.15 & 11.45 – 12.30. I understand that children are the responsibility of their parent or guardian outside of the morning session times.* Yes I understand that children who have not yet started Secondary school will need an adult with them to participate in out of session activities, including walks & workshops* Yes Photograph ConsentPlease choose all you are happy with* I give permission for a member of the Scargill Team to take photographs & videos of my child/young person for use only within house in the photo montage at the end of the week I give permission for photographs or videos taken of my child/young person by a member of the Scargill Team to be used in promotional & marketing material, such as presentations, display boards, & programmes to promote Scargill House I give permission for photographs & videos taken of my child/young person to be shared via Scargill’s digital media sites, including our website & Facebook page I do not give permission for a member of the Scargill Team to take any photographs or videos of my child/young person We ask all of our guests not to take photographs of other people’s children unless they have express permission.Your data will be processed securely by Scargill Movement. See our Child & Young Person Registration Form Privacy Notice.Thank you for your cooperation. We look forward to welcoming you, your children, & young people very soon. Blessings from The Scargill Youth Team
