Membership Form

First name *

Last name *

Attendee School Or College *

Attendee Email Address *

Mobile phone *

Address line 1 *

Address line 2

Town/City

Postcode *

Nickname

Gender *

Date of Birth *

I am 16 or over

Contact relationship type

You are stating that you are the adult responsible for this young person and give your consent to be registered on Youth Active (which includes permission to attend sessions).

Contact first name

Contact last name

Parent / Guardian Info

Name Of Parent Or Guardian *

Parent or Guardian Mobile Number *

Parent or Guardian Email Address *

Emergency Contact Details

Emergency Contact First Name *

Emergency Contact Surname *

Emergency Mobile Number *

Contact email address *

Medical Info

Does the young person named suffer from asthma, hay fever, migraine, fits, faints, or any other illness? *

Are participant allergic to anything? (for example, Antibiotics, Elastoplast, Aspirin, any other medicines, animals, or any food etc.) *

Specific medical conditions

Do you have any additional support needs whilst you are attending the Youth Club that we should be aware of? *

Permissions

I give permission for the use of photos or other media featuring me (or the person for whom I'm completing this form)

I want to receive updates and newsletters from Youth Active via email.

Additional Info

Which ethnic group do you identify with?

Language spoken at home

What type of activities interest you?

How did you hear about Youth Active

Confirmation

Terms & Conditions and Privacy Policy

I understand in the event of injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately.

I understand that the young person named is responsible for their own personal belongings and Youth Active cannot be held responsible for replacing anything that is lost, damaged or stolen.

I accept the organisation's Terms & Conditions and Privacy Policy *

Finally, please confirm you are a real person. *