Participant Consent Form
This personal information will be kept securely on file and represents your permission for us to work with the below named individual for the foreseeable
future
Personal Details
First name
Family name
Gender
Date of birth
Age
School
Postcode
Mobile no.
Email address
Medical Details
If you are in any doubt about completing this part of the form please consult your doctor first. We
will only use the information that you provide us with in relation to this programme.
Have you any history of physical disability or illness that we should be aware of that may affect your
involvement in the programme? Please tick.
YES NO Please give details:
Back problems
Knee or ankle problems
Asthma or breathing problems
Prone to fainting or dizziness
Epilepsy
Allergies Do you carry an Epi Pen YES NO
High blood pressure
Heart condition
Diabetes
Physical Disabilities
Infectious diseases
Other (give details)
Have you had a tetanus injection within the last ten years? YES NO
Other medical information. Please give details.
Please give details of any medical treatment and / or drugs that you are receiving.
Doctor's details (please specify name, address and telephone)
Do you have any special dietary requirements?
Vegetarian Halal
Vegan Gluten Free
Nut Allergies Kosher
Other (please specify)
For outdoor projects we can supply you with waterproofs (jacket and over trousers) and walking boots.
For some outdoor projects you may be required to wear protective equipment such as climbing helmet, body harness or life jacket. Please state any reason
why you WOULD NOT be able to wear such equipment.
Emergency Contact Details
In an emergency, who should we contact?
Name
Relationship
Telephone number
Mobile number
Other Concerns or Issues
Please add comments below if there any issues or concerns around:
Confidence in water
Additional needs
Learning difficulties
Mobility issues
Other Concerns or Issues
Equal Opportunities Information
Gender: Male Female Prefer not to say
Ethnicity: Asian/Asian British White - other background
Black/Black British Mixed ethnicity
White British Other ethnic group
Consent - please sign the below statement
Contact/Photos - please tick the below statements
I agree to:
* Photos, interviews and video footage to be taken and shared with the school and other participants
Photos, interviews and video footage to used on printed publications on the organiser's website, on Social Media and in
*
public broadcast, to promote the work of Wigan Council
* Being contacted in the future by our joint intelligence team for monitoring purposes.
* Being contacted in the future by our marketing team with details of future offers for further development opportunities.
In signing for a participant who is under 18 years of age:
* I have read the personal information above an confirm it is correct and complete and agree to the named participant taking part in the programme and/or
attending the Outdoor/Personal Development Residential in the Lake District. I understand the organisers of the programme will make contact by
letter/phone/email with further details of the programme
* I understand that Wigan Council staff have a Duty of Care when they are running activities but that responsibility for the pastoral care of the named
participant rests with the visiting course leader who is in loco parentis.
* I acknowledge the need for the above participant to behave responsibly and to adhere to an agreed Code of Conduct whilst working with Wigan Council. I
understand that if they are sent home it is my responsibility to collect them and/or make suitable arrangements for this at my own cost. I also understand
that any costs for damage they cause will normally be passed on to their parent/guardian.
* I agree to the above named participant receiving medication as instructed and any emergency treatment as considered necessary by the medical
authorities present.
I confirm that I have read and understood the above an, I or the person named below, will be available during the dates shown if
you need to contact me/us.
Parent/Guardian Name
Signature Date
Telephone Address
PLEASE MAKE SURE THE PARENTAL CONSENT MARKED IN RED ITALICS HAS BEEN SIGNED
Wigan Council holds personal data in accordance with the General Data Protection Regulations (GDPR). We hold your personal data as set out in our Data Primary Privacy
Notice and Public Relations Privacy Notice which can be viewed on the Council’s website (www.wigan.gov.uk) If you would like any guidance please contact
GDPRQueries@wigan.gov.uk.
Wigan Council uses anonymised monitoring and evaluation data from, all programmes to evidence the effectiveness and quality.
