Parent/Guardian Booking Form
Please be assured this information is held in confidence and only shared with the Activity Provider in the interests of welfare
and safety. Contact Splash if you have any queries
Please complete this form as fully as possible. If the form is not completed it may be returned
Name of
Relationship:
Parent/Guardian:
Address:
Tel:
Would you like to be
added to our email
Mobile:
distribution list?
Email:
YES/NO
How did you hear about Splash?
YOUNG PERSONS
DETAILS
Address:
Name:
Date of Birth:
(dd/mm/yyyy)
As Above (please tick box)
Does this young person have any
If YES please give details
ALLERGIES or INTOLERANCES?
MEDICAL
FOOD
YES/NO
YES/NO
Will the young person need to take medication during the project?
Age:
Home Contact Number:
YES/NO
School Attending
Has a common assessment
framework (CAF) been done with
this young person?
YES/NO
(If yes, please contact the Splash office, with details. Please note the young person must be able
to administer their own medication Splash staff are not qualified to administer any medication)
Is the young person’s
YES / NO
Does this young person present a risk?
tetanus immunisation
(please circle all that apply) If yes please give
To themselves
up to date?
more details on Page 2.
White
British
White Irish
Any other white
background
MALE/FEMALE
(Please Circle)
To others
Ethnicity of young person- Please tick the boxes that apply
Mixed/Multiple ethnic groups
Asian /Asian British
Chinese or
Other
White and Black Caribbean
Indian
White and Asian
Pakistani
Chinese
White and Black African
Bangladeshi
Other
Any other Mixed/ Multiple ethnic background Any other Asian background
To Staff
Black / Black British
African
Caribbean
Any other black
background
BOOKING CATEGORY & MEDICAL INFORMATION – PLEASE CIRCLE ALL BOXES THAT APPLY
(Splash collects this information to ensure we can fully support each young person attending. We also use data collected in funding
applications and evaluations.)
A.ABC/ASBO
B.Engaged in YOT
C.Anti-social/negative
D.Non/poor/reluctant
E.Area of Deprivation
behaviour
school attendee
F.Family under
G. Parent/ YP
H. Child protection
I. Children looked after
J. Young carer
stress
substance misuse
plan/issues
(in care)
K.Involved in
L. Behavioural /
M. Statement of SEN
N.Financially
O. Asylum seeker/
negative peer
Emotional/ learning
disadvantaged
traveller/ minority
group
difficulties
group/ parents in
Armed Services
P. Single parent
Q. Homeless/
R. Victim of bullying/
S. Rural isolation
T.Seeks new opportunity
family
temporary
crime/physical/ mental
accommodation
abuse
U. Autistic
V. ADHD/ADHA/ASD
W. Epileptic
X.Diabetic
Y. On Medication
Spectrum
Disorder
Y. On free school
Does this young
Is this person in
Is young person
School
meals
person consider
receipt of a disability water confident
attendance over
Military Family
themselves to have
living allowance?
(can they swim)
last school year:
YES/NO
additional needs?
YES/NO
YES/NO
0-100%
YES/NO
%
SP8
Parent/Guardian Booking Form
Please help us to support this young person at Splash projects, please include information which you consider would be useful for us,
and the Activity provider to know. (Continue on a separate sheet if necessary) (Must be completed)
Why are you
nominating this
young person?
strengths
Difficulties/challenges
personal issues
reactive behaviour
Please give details of any other agencies
working with this young person:
EMERGENCY CONTACT DETAILS -(Please give details of who we should contact in an emergency)
If the emergency contact details are the
same as nominator details please sign:
Name:
Relationship to young person:
Address:
Tel:
Mobile:
Email:
Projects Wishing to Attend
Holiday period
Project
SPLASH CONSENT 2015-2016 (Please tick the appropriate boxes)
I give permission for ……………………………………………………………………………………..……………(enter young person’s name)
 To attend Splash projects during the year 2015-2016 as advertised by Splash, Community First and Youth Action Wiltshire and as
detailed in the project confirmation letter. Projects can include Sports, Arts, Dance, Cooking, Wildlife; Water based activities,
mountain biking, climbing, and extreme sports.
 To have photographs and videos taken which may be used for Splash, Community First and Youth Action Wiltshire publicity
purposes and social media (Facebook & Twitter)
 To receive first aid treatment if required during a project
 I give Splash/Community First/ Youth Action Wiltshire permission to keep the booking form and young person’s information on file
for data purposes and so we can contact you with details of future Splash projects and other positive activities in your area.
The personal information you provide is for the purpose of processing your application for a Splash project; it will not be processed, or
disclosed, in any way incompatible with that purpose. In accordance with the principles of the Data Protection Act 1998 the
information may only be disclosed to the Data Subject (yourself) or with your permission. We may share this information with others
for the purpose of processing this nomination and delivery of the project. Please also note this information will be passed on without
permission if there is a legal requirement to do so, or, if there is a risk of harm or threat to life.
PLEASE NOTE
Name of parent/guardian……………………………………………………………………....
 Splash places are limited and costly.
I am the person with parental responsibility
 If a young person cannot attend, Splash requires a
24 hour notice period in order to fill this place
Signature……………………………………………………………………Date……………………
 If a young person does not attend two confirmed
Splash days for whatever reason without giving 24
Name of young person……………………………………………………………………….......
hours notice they may not be guaranteed a place
on a future project.
 Splash reserves the right to charge for non
Signature……………………………………………………………………Date…………………..
attended places. The average cost of a Splash
place is £60.00
Please return this form to: Splash Wiltshire, Community First, Unit C2, Beacon Business Centre, Hopton Park, Devizes, SN10 2EY
01380 732829, www.splash-wiltshire.org.uk
SP8