Name of Project: Date(s) of Participation:
Section 2: About the Child
Name:
Address:
Tel No: Date of Birth:
Section 3: About You
Please state your relationship to the child:
If you are not able to be present with the child during the course of the Project please nominate the person acting as loco parents for your child
Name the person acting as loco parentis:
Please state their relationship to the child:
Section 4: About the child's health
Has the child EVER suffered from any of the following complaints?
Asthma: Skin Complaints: Allergies: Heart Problems:
Epilepsy: Back Problems: Migraines: Phobias:
If YES please give details
Does the child have any specific requirements, e.g sight, hearing, dietary or other? If YES please detail:
Please describe any support requirements related to the health issues outlined above
If you child has a hearing impairment, please tell us how they like to be communicated with: lip reading, BSL or interpreter support:
Please describe any coping or calming techniques you use with your child in relation to health issues outlined above
Is the child on any form of medication, if so what type and for what?
Section 5: About the child's doctor
Name:
Address:
Tel No:
Please sign below to conform that a) you agree to the terms and conditions set out on pages 1&2; b) the child is physically fit to participate in the project; b) you consent to the BBC contacting the child's GP if there is a need to clarify the child's fitness, and c) the above information is correct.
Signed: .................................... Print Name: ............................ Date: ...............................
(Parent/guardian)