Junior Church Registration Form – Kidlington with Hampton Poyle Anglican Churches

Full Name of Child *

First

Last

Child's date of birth (dd/mm/yyyy) *

Address *

Postcode *

Full Name of Parent/s *

Relationship to child *

Phone number *

Email *

Doctor's surgery

Doctor's name (if known)

Surgery phone number

Please list any medical condition(s) your child may suffer from (e.g. asthma, epilepsy etc)

Does your child currently take any medication? *

If yes, please provide details of the medication. Please also provide details of when/how your child should take their medication during the activity (if applicable).

Does your child suffer from any allergies (e.g. food, drink, medication etc)? *

If yes, please provide details of the type of the allergy and the medication used to control the allergy

In the event of an emergency and if we are unable to contact you, please provide the name and telephone number of an alternative emergency contact (e.g. a friend or relative).

Name *

Relationship to the child *

Contact number *

Please tick if you are happy for photos, videos and audio to be taken of your child for Kidlington and Hampton Poyle Parish purposes, including livestreaming of services/concerts and publicity (eg Facebook and church website) (no full names will be used)

Please tick to confirm that you have discussed the above with your child and they consent to their photo, video and audio being used in this way.

Please tick if you are willing for your child to walk to and home from groups unattended by an adult

Please tick if you give permission for your child to be driven in a youth leader's car when/if necessary

I agree to my child participating in Junior Church including the activities organised. I acknowledge the requirement for my child’s obedience and responsible behaviour during this activity. In the event of an emergency I consent to any emergency medical/dental treatment that my child may require prior to my arrival. (Every effort will be made to contact you through the details you have given above.)

Personal information which you supply to us will be used only for pastoral support and will be made available only to authorised members of the Parish of Kidlington with Hampton Poyle. You can find out more about how we use your data from our “Data Privacy Notice” which is available from our website or from the Parish Office. You can withdraw or change your consent at any time by contacting the Parish Administrator at Parish Office, St John’s Church, Broadway, Kidlington, OX5 1DD, office@kidhp.org.uk, 01865 375611. Please note that all processing of your personal data will cease once you have withdrawn consent, other than where this is required by law, but this will not affect any personal data that has already been processed prior to this point.

Please indicate which method(s) we may use to contact you (it is most helpful if you are able to consent to all three methods of communication):

Post
Phone
Email

By writing my name here I am agreeing to these details of myself and my child being held on a database for this purpose.

Date (dd/mm/yyyy)