Registration form for children and young people attending sessions at Scargill House Date of Arrival*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Personal DetailsName* First Last Likes to be known as Address* Street Address Address Line 2 City County Post Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Contact name & number*Parents email address* GenderSchool Year in September 2018*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.*YesI understand that I will be contacted if an accident should occur that requires more than basic first aid.*YesI 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.*YesIf 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.*YesNoAdditional NeedsPlease contact the Youth Team on 01756 760500 if you would like to discuss your child, or young person's needs directlyDoes 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?*YesNoUnfortunately, Scargill cannot provide one - to -one care or sessions, so for some children with specific additional needs it may be necessary for the family to provide an adult to support them in the sessions. Bursary money can be made available for a family to bring an additional carer with them if this is what is needed to fully include the child or young person in all our activities. It would be expected that this adult would attend all activities with the child. 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 areplanning 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 any children that have not yet started Primary School full-time.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 ismy responsibility to bring them to sessions and meet them in the Sun Lounge for 11am and 12:30pm*YesMy 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.YesNoOut of Session ResponsibilitiesCreche runs 10.00-11.00, and the youth & children's sessions (5 - 17 yrs) from 10.00 - 11.00 & 11.30 - 12.30 I understand that children are the responsibility of their parent or guardian outside of the morning session times.*YesI understand that children who have not yet started Secondary schoolwill need an adult with them to participate in out of session activities, including walks & workshops*YesPhotograph ConsentPlease choose all you are happy with* I give permission for a member of the Scargill Team to take photographs & movies of my child/young person for use only within house I do not give permission for a member of the Scargill Team to take any photographs or movies of my child/young person I give permission for photographs or movies 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 & movies taken of my child/young person to be shared via Scargill's digital media sites, including our website & Facebook page Thank you for your cooperation. This form will be retained for 12 months from the date of the event. We look forward to welcoming you, your children, & young people very soon. Blessings from The Scargill Youth TeamEmailThis field is for validation purposes and should be left unchanged.
