Westminster Youtth Ministry Reegistration Forrm | dowym.ccom | 0207 52
29 8633 Pilgri
P im C
Conssentt Forrm
WORLD Y
YOUTH
H DAY K
KRAKOW
W 2016
6 18 to 31 Jully Dear Parent/Guaardian, Plea
ase completee the form b
below if: • Your child is under the aage of 18. o World Youtth Day from 18 to 31 of July 2016 – • You are happy for your cchild to take part in the ppilgrimage to
spending tim
me in both Łó
ódź and Krakkow. medical treatm
ment during the pilgrima
age. • You are happy for your cchild to be giiven first aid or urgent m
ographs or film of your chhild to be use
ed in relation
n to the pilgrrimage or W
Westminster • You are happy for photo
Youth Ministtry publicity. Yours sincerely, Phil Ross Dire
ector of Youth Ministry Dioccese of Westtminster 1 C
Child deetails Nam
me of child Parish name Parish town 2 P
Photogrraphs I am
m happy for p
photographs//films of my son/daughteer to be used
d in relation to the pilgrim
mage or in W
Westminster Youtth Ministry p
publicity/pub
blications. I give permission
n for my child
d to be phottographed w
whilst on pilgrrimage or at any meetinggs or reflections that pre‐
date
e or post‐datte the pilgrim
mage. Signed (Parent/C
Date: Carer): Page 1 of 3
Westminster Youth Ministry Registration Form | dowym.com | 0207 529 8633 3 Medical Information Please provide details of any medical condition your child has, including regular medication needs, e.g. epilepsy/asthma/inhaler, diabetic/insulin/migraines etc. Please also provide the name, address and telephone number of your GP/Medical Centre. Medical conditions Allergies Does your child suffer from travel sickness? If so, do they take any medication (and what is it)? 4 Doctor’s details Doctor’s name Doctor’s address Postcode Doctor’s telephone number I give full permission for members of Westminster Youth Ministry staff to authorise emergency medical treatment in an emergency for my child and also to administer minor first aid if needed. Signed (Parent/Carer): Page 2 of 3 Date: Westminster Youth Ministry Registration Form | dowym.com | 0207 529 8633 5 Consent Form of Indemnity I agree that: 1. I will pay for any damage to persons or property, which is caused through the misconduct or carelessness of my child. 2. I will not hold Westminster Youth Ministry or the Diocese of Westminster or any member of staff responsible for any loss of personal effects by my child during the trip where reasonable steps have been taken to safeguard those items. 3. I will reimburse Westminster Youth Ministry or the Diocese of Westminster and any member of staff in respect of any accident to, or illness of my child, or for any other reason where expenses are incurred. 4. I shall repay such expenses as quickly as possible. 5. I consent to my child travelling by any form of public transport or in a motor vehicle driven by any member of staff who accompanies the trip and is in possession of a full driving licence valid for the vehicle concerned. In relation to the points above please note that parents/carers will not be asked to repay any sum of money where the sum has been the subject of a successful insurance claim by Westminster Youth Ministry or the Diocese of Westminster or any member of staff. If you have any concerns regarding your child’s health which may affect the pilgrimage please provide a brief outline below: I note that I will inform the school if I have any concerns regarding any medical complaint or treatment needed which may affect my child’s participation in the pilgrimage. Telephone numbers where parents/carers may be reached in an emergency. Home Work Mobile Mother Father Carer Other Family Member I hereby sign the Consent Form to give permission for my child to take part in the pilgrimage and agree to the conditions in this agreement. Signed (Parent/Carer): Date: Page 3 of 3