MLCE Membership & Registration Form

YOUNG PERSON’S DETAILS

Name

Address

Date Of Birth

Sex

Phone Number

Religion

Ethnicity

PARENT/CARER DETAILS

Name

Address

Tel No 1

Tel No 2

MEDICAL INFORMATION

In the interest of your child’s health and safety, please inform us of any relevant information concerning welfare issues, including social/emotional behavioural factors which staff needs to be aware of. Any information will be treated as confidential by staff.

Do you consider your child to have a learning difficulty or disability? If ‘YES’ please specify

Yes

No

if Yes

Do you consider your child to have a learning difficulty or disability? If ‘YES’ please specify

Yes

No

if Yes

Do you consider your child to have a learning difficulty or disability? If ‘YES’ please specify

Yes

No

if Yes

Emergency contact name (other than already listed above)

Relationship to child

Telephone number 1

Telephone number 2

FILMING & PHOTOGRAPHY CONSENT

By enrolling your child you acknowledge and agree without further consent that they may be videoed and/or photographed during the activities they are engaged in. We will use the images to represent, promote and illustrate our work with residents and customers. Images are managed by ML Community Enterprise and may be reproduced in publications, public relations (PR), electronic media and other promotional materials.

You have the right to request to see a copy of the information we hold about you and to request corrections or deletions of the information that is no longer required.

You have the right to withdraw your consent at any time, in which case your images will not be used in future publications but may continue to appear in publications already in circulation. You can withdraw your consent by contacting: ML Community Enterprise Ltd, Marcus Lipton Centre, Minet Road, London SW9 7UH, Tel: 0203 137 1161, info@mlce.org.uk

Members Signature:

Clear

Date

Parent/Carers Signature:

Clear

Date

CONSENT & INDEMNITY

1. I understand that some activities have a carefully controlled element of risk. I consent to my child receiving any medical treatment considered necessary by a doctor in an emergency. In an emergency, MLCE or its representative may authorise medical treatment including anaesthetic for the participant if it is not practical to call me first. If it is appropriate in the circumstance to consult a doctor, MLCE will only act on their recommendation.

2. I understand that the right to use the service may be withdrawn if my child’s behaviour is unacceptable and does not improve after discussion with me.

3.By signing this I am consenting to my child being a member of MLCE and for my child to take part in any programme or activities delivered through MLCE or its representatives.

4.I acknowledge to abide by the young people’s code of conduct set by MLCE

5.
I accept that the applicant is responsible his his/hers own personal belongings and that neither MLCE nor its representatives will be liable for any damage or loss to such personal belongings.

6.I agree to indemnify MLCE and their representatives from all liabilities in relation to loss or damage suffered or caused by the applicant which result other than by the negligence of the programme or any of its representatives or which result from the applicant failing to follow any reasonable instruction given. Please note that ‘representatives’ include all officers, employees and agents of MLCE.

7.I confirm that the information contained in all the sections of this form are accurate and complete and true to my knowledge and I will inform MLCE if there are any changes.

DECLARATION

MLCE needs to use the information on this form to report back to our funders, who fund the work at Marcus Lipton Centre. These funders are GLA, Lambeth, MOPAC, The Home Office, London Community Foundation and the NHS. All the information will be stored securely, only accessed by authorised staff and made anonymous when it is reported on. If you have any questions about this, or how your data is stored, please ask a member of staff.

You can change these permissions at any time by asking a member of staff and you also have the right to see all of the information we hold about you.

Membership & Registration Form

We also take photos of our projects to publicise our work, seek further funding and tell others about the work we do here.

MLCE Privacy statement is available on our website, or you can ask staff for a copy at any time.

Please tick the below boxes to consent to your data being stored and used as detailed below. Any questions please ask a staff member.

I DO consent to the data on this form being stored electronically and shared with funders

I DO consent to being contacted by MLCE about events, trips or services they think would be of interest to me

I DO consent to the child I have parental responsibility for being photographed or filmed, which I understand may be used to promote the work of this project and the work of MLCE

Signature

Clear

Date

*This form can only be signed by the parent or carer with whom the children normally live

By ticking this box you agree to share your name, postcode and email address with Building Young Brixton so you can receive information about activities and opportunities to get involved. You can unsubscribe at any time.

Yes please! (Please tick)