HOLIDAY MISSIONS

WHO ARE YOU? FORM Year 2015Surname

First Name

Age Year group* Date of Birth

Home Address

Post Code

Holiday Address

Post Code

Name of parent(s)/guardian(s)

Parent/guardian email

Emergency Contact 1

Name

Relationship

Home Number

Mobile

Emergency Contact 2

Name

Relationship

Home Number

Mobile

Name of Church (if attended)

Name of School *

*Please give school / year group for next year.

Please give details of any medical conditions (e.g. asthma, epilepsy, diabetes, allergies, dietary needs) or disability that may be affected by this activity

Group Leader

Authorisation of Parent / Guardian:

My child is permitted to attend and participate in all the activities of the mission.

I (having parental responsibility for the above named person) give consent to any emergency medical treatment that may be necessary during the duration of the mission.

Please tick if appropriate:

My child is permitted to walk home alone (I give permission for my childs name to be passed on to the SU Coordinator or SU Rep in their school, to let them know that they have attended this event

(Photographs and video

Some photographs and video taken on SU activities are used in publicity materials and on the SU or Team Website, including Social Media e.g. Facebook. In signing this form you consent to photographs and video being used for such purposes.

Please tick here if you DO NOT want photographs to be used for these purposes.

(Signed:

(Parent / Guardian)

Date:

DATA PROTECTION: In returning this form you agree to the Team Leader holding your contact details as part of a computer record. The Team Leader will not share this information with any other agency, but may, from time to time contact you or your child/young person to let you know about reunions or to give you information about summer 2011. We will not hold this information for longer than in necessary.