ECF – Illuminate Stroud

illuminate Stroud
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Details of Young Person

This form should be completed by a young person aged 13 years or over or by their legal guardian.

Title

Full name of young person *

First

Last

Preferred Name

Date of Birth *

Sex

Ethnicity/Nationality

School or College

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Emergency Contact Details

These details will be used to keep you safe

Full name of Parent (Or person with Parental Responsibility) *

First

Last

Address if Different from Above

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Phone - Mobile *

Relationship to young person (Mother, Father, Aunt etc) *

Emergency Phone - Home

Emergency Phone - Work / Other

Email *

Health and Wellbeing

If you have any allergies / dietary requirements, ongoing medical requirements, disabilities or impairments please provide details in this box

Health and Wellbeing

Further Details

Are you currently receiving any other support from The Door?

Telephone Support
I have a Mentor
Something else

Are you currently associated with any particular church or church group?

Which youth club / activity are you planning to attend? (copy)

Where did you find out about illuminate?

Photo Consent (optional)

I give my consent for photos and videos of the young person named above to be taken by The Door whilst participating in The Door’s activities, and for The Door to use these photos/videos in their fundraising and publicity.

Friend of The Door (optional)

I would like to stay up to date with The Door’s work through a monthly e-newsletter to be sent to the address above and receive 10% off in the charity shop by becoming a Friend of The Door.

GDPR Agreement (required to submit form) *

I consent to The Door storing and processing my personal information for use in connection with my safety or the safety of others. I understand that it may also be used on anonymised basis for the purposes of monitoring and improving The Door’s services.

illuminate StroudJoin us in Stroud, Dursley and on social media.

Details of Young Person

Emergency Contact Details

Health and Wellbeing

Further Details

illuminate Stroud
Join us in Stroud, Dursley and on social media.