12TH WALLASEY SCOUT GROUP

Please select which section of the Group your child is in:

Beaver Scouts
Cub Scouts
Scouts
Explorer Scout Young Leader

Young Member's Title: e.g. Mr, Master, Miss etc...

Young Member's Surname:

Young Member's Forename(s):

Young Member's Date of Birth:

Young Member's Gender

Female
Male
Other
Prefer Not To Say

Young Member's Known as name (nickname, or abbreviated name):

Young Member's Nationality:

Young Member's Ethnicity (please select from below):

White English/Welsh/Scottish/Northern Irish/British
White Irish
White Gypsy or Irish Traveller
Any other White Background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed/multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black African
Black Caribbean
Black British
Any other Black/African/Caribbean background
Arab
Other ethnic background not mentioned
Prefer not to say

Ethnicity - If you selected 'other ethnic background not mentioned' please state below:

What is the young person's religion (please state all that apply):

No religion
Christian (including Church of England, Catholic, Protestant and other Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion, please write in the box below

Religion - if you have selected 'Any other religion' pleaese specifcy below:

Young Member's School/College/University

Young Members Home Address details:

House Number/Name & Road

Town:

County:

Postcode:

YOUNG PERSON'S MEDICAL DETAILS

Doctor/Surgery Name:

Doctors/Surgey Adddress (including postcode):

Doctor/Surgery Phone Number:

NHS Number of Young Person if known:

Dietary Needs - please detail any specific requirements of the Young Person named above:

Medical Information - please detail any medical conditions, treatment(s) medication(s) for the Young Person named above:

ADDITIONAL NEEDS, SUPPORT & DISABILITIES

Please tick all that are relevant and provide details in the information box below:

Developmental - e.g. ADHD?ADD. Autistic, Dyslexia, Dyspraxia, Other.
Injury - e.g. Body, Brain
Physical - affecting mobility e.g. Spina Bifida, Down's Syndrome, Other
Medical - e.g. Allergies, Asthma, Arthritis, Diabetes, Epilepsy, ME, Other.
Mental Health - e.g. Bipolar, Depression, Anxiety, Eating Dissorder, Self-Harm, Other
Progressive - e.g. Muscular Dystrophy, Other
Sensory - affecting sight
Sensory - affecting hearing
A disability not covered above

Additional Information for needs & disabilities

Young Person's Additional Activities - please provide details of any sports, clubs, hobbies or interests:

Young Member's Swimming Capabilities:

The Young Person named above can not swim at all
The Young Person named above can swim at least 50 metres (two lengths of Guinea Gap Training Pool)
I do not know the swimming abilities of the Young Person named above.

CONTACT 1 - Designated Primary Contact for the Young Person named above:

First Parent/Guardian Information

Title:

Surname:

Forename

Known as:

Relationship to Young Person named above:

Gender

Click here to select
Female
Male
Other
Prefer Not To Say

Date of Birth (Optional)

Please tick here if the address is the same as the young person named above. If Different, complete the full address details below.

Tick here to confirm contact 1 shares the same address as the young person named above

Address (if different from the young person named above):

Home Phone Number

Mobile Phone Number

Work Phone Number (if required for emergencies):

Primary Email Address (to be used for all group communications)

Second Email Address (if applicable)

Occupation:

Please click here to select from the list:
Employed
Unemployed
Retired (whether receiving a pension or not)
Student
Looking after home of family
Long-term sick or disabled
Other

Occupation Details (optional):

Hobbies & Interests (optional):

Please provide details of any previous Scout/Guide/Cadet activities & membership (optional):

GIFT AID for Parent/Guardian 1

I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs (CASCs), that I donate to, will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand the charity will reclaim 25p of tax on every £1 that I give. Please notify The Scout Association if you: 1. Want to cancel this declaration. 2. Change your name or home address. 3. No longer pay sufficient tax on your income and/or capital gains. If you pay income tax at the higher rate, you must include all your Gift Aid donations on your Self Assessment tax return if you want to receive the additional tax relief due to you.

Please tick here to confirm this statement applies to your circumstances
Please tick here to indicate that you wish for all payments of money made in the past four years and all future payments made from the date of this declaration to be treated as Gift Aid donations to the 12th Wallasey Scout Group

Social Media User Names (Optional) We ask for this information to verify any parents following or posting on the Group's social media pages:

Facebook username (if applicable)

Twitter username (if applicable)

Google+ username (if applicable)

CONTACT 2 - Designated Secondary Contact for the Young Person named above:

Second Parent/Guardian Information

Title:

Surname:

Forename

Known as

Relationship to young person named above:

Gender

Click here to select
Female
Male
Other
Prefer Not To Say

Date of Birth (Optional)

Please tick here if the address is the same as the young person named above. If Different, complete the full address details below.

Tick here to confirm contact 2 shares the same address as the young person named above

Address (if different from the young person named above):

Home Phone Number

Mobile Phone Number

Work Phone Number (if applicable)

Primary Email Address

Second Email Address (if applicable)

Occupation:

Please click here to select from the list:
Employed
Looking after Home or Family
Long-term sick or disabled
Retired (whether receiving a pension or not)
Unemployed
Student
Other

Occupation details (Optional):

Hobbies & Interests (Optional):

Please provide details of any previous Scout/Guide/Cadet activities & membership:

GIFT AID for Parent/Guardian 2

I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities or Community Amateur Sports Clubs (CASCs), that I donate to, will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand the charity will reclaim 25p of tax on every £1 that I give. Please notify The Scout Association if you: 1. Want to cancel this declaration. 2. Change your name or home address. 3. No longer pay sufficient tax on your income and/or capital gains. If you pay income tax at the higher rate, you must include all your Gift Aid donations on your Self Assessment tax return if you want to receive the additional tax relief due to you.

Please tick here to confirm this statement applies to your circumstances
Please tick here to indicate that you wish for all payments of money made in the past four years and all future payments made from the date of this declaration to be treated as Gift Aid donations to the 12th Wallasey Scout Group
Please tick here to indicate you are the second contact and your electronic signature is required below

Second parent needs to complete this declaration in resect of Gift Aid:

Gift Aid Declaration - Signed Electronically By:

Gift Aid Declaration - Insert Date of Signing

Social Media User Names (Optional) We ask for this information to verify any parents following or posting on the Group's social media pages:

Facebook username (if applicable)

Twitter username (if applicable)

Google+ username (if applicable)

ADDITIONAL SUPPORTING INFORMATION

Photographs and videos are regularly taken during our scouting adventures, and these may be used to keep you up to date with activities on the group social media accounts, and can be used for publicity purposes, including the local press and social media, in which your child can be identified. Please note - we will never publish the full names of any child without express permission, and it most cases refer to young members by their section, i.e. Beaver Scout. We also use the photographs and videos taken throughout the year in our annual celebration evening. Could you therefore please select the appropriate response below in relation to the young person named above:

I consent to my child appearing in photographs and videos where they can be identified.
I do not consent to my child appearing in any photographs or videos
Click here to change

Having a public park on the doorstep of our headquarters provides the opportunity for sections within the Group to take advantage of the space for outdoor fun and activities. For using the park at short notice we need your permission

Please tick this box to give permission for the young member named above to accompany the 12th Wallasey Scout/Cub/Beaver Section Leaders, Assistants and any Occasional Helpers to Central Park for games and activities during normal meeting times.

When young members attend camps, activities and events outside of our weekly meeting parents/guardians need to provide health information and emergency contact details. To prevent the need for this information being provided by you multiples of times throughout the year, we intend to email the relevant sections of this form back to the primary contact prior to events and activities so we can check all health and personal information is current and up to date.

Please send the relevant information in need of checking before events and activities to contact 1 only
Please send the relevant information in need of checking before events and activities to both contact 1 and 2.

Disclaimer: If it becomes necessary for the above named young person to receive medical treatment and I cannot be contacted to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the Leader in Charge to sign any document required by the hospital authorities. I have provided all of my child’s medical information and my child is fit to participate in the camp / night away.

Please check the statements below and tick to confirm before signing and submitting this form:

I have fully read the 12th Wallasey Scout Group Member Information Pack
I have set up a standing order to pay subscriptions
I have paid the joining fee by standing order / cash / cheque
I have read and understand the Group Membership Policy for Parents and Children
I have read and understand the Group Behaviour Policy
I understand I must notify the Scout Group if any of the details submitted on this form change
BOTH CONTACTS consent to the 12th Wallasey Scout Group collecting, storing and processing the personal data provided on this form.
CONTACT 1 - I consent to the 12th Wallasey Scout Group contacting me by Email, Phone and Post.
CONTACT 2 - I consent to the 12th Wallasey Scout Group contacting me by Email, Phone and Post.

The 12th Wallasey Scout Group collect and process data in accordance with our Privacy Policy, linked above, for our need to be compliant with policies of The Scout Association. By signing this form electronically you are consenting to the 12th Wallasey Scout Group holding and processing the data you have provided, both during and beyond your child's membership.

Signed Electronically by Contact 1:

Date of Signing by Contact 1:

Signed Electronically by Contact 2 (if applicable):

Date of Signing by Contact 2 (if applicable):

Please note: once this form is submitted, it will be checked by the Group Scout Leader and passed to the relevant Section Leader for their records. A copy of the submitted form will be emailed back to contacts 1 (and 2 if applicable) for their checking.

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