Well Centre August Activities - BOOKING FORM
YOU MUST BOOK IN ADVANCE
Please complete and return this form to book your place.
Please tick the activities you would like to attend:
Photography
Horse riding
Graffiti
First aid
Bike riding
YOUNG PERSONS DETAILS
Full Name:
Date of Birth:
Mobile/SMS:
Email:
Address:
MALE / FEMALE
Age:
FIRST EMERGENCY CONTACT*
Parent/Carer's Name:
Telephone:
Full Name:
Relationship to youth:
Telephone:
Mobile/SMS:
SECOND EMERGENCY CONTACT
Mobile/SMS:
* Parents/carers please ensure you are contactable on these numbers during the event.
MEDICAL DETAILS
Medical Conditions: (inc. details of any activities you are not able to do for medical or other
reasons)
Prescribed Medicines:
NB: Bring all required medicines and equipment with detailed instructions to event.
Disabilities:
Wheelchair User:
Allergies / Dietary Needs:
YES / NO
FURTHER DETAILS: Please give any further information or any details that you think might be useful
to us e.g. fears/phobias, behaviour, special needs etc.
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YOUR AGREEMENT
I undertake not to hold the Well Centre, Redthread or Herne Hill Group Practice responsible for
compensation in respect of loss or damage to personal property, which I sustain during any
events or activities.
I understand the importance of advising the Well Centre of any medical or special needs that
may require particular attention in order to enable my full and safe participation in the event.
I will not attend activities or events if I am not in good health or have been in contact with an
infectious disease within two weeks of the commencement of the activity or event.
If at any point during an event I require urgent medical treatment, I give permission to the
medical authorities to administer such emergency treatment, including anaesthetic, as they
consider necessary in the circumstances.
In regards to the photography workshop I understand that I have the right to withdraw my
consent if I later change my mind (as explained in the information sheet).
Young Person’s Signature:
Date:
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PARENT / CARERS CONSENT FORM
(for participants aged under 18yrs old)
I confirm that I accept the agreement as detailed above and consent to my son/daughter
(named above) taking part in this event.
In regards to the photography workshop I understand that I have the right to withdraw my
consent if I later change my mind as detailed in the information sheet.
Parent / Carers Signature:
NAME IN CAPITALS:
Date:
IMAGE CONSENT
The Well Centre, Redthread and Herne Hill Group Practice like to document their work, including
events and activities. The images may be used for internal documents, marketing and press,
including the internet.
Agreement:
 I agree to my image being used by the Well Centre, Redthread and Herne Hill Group Practice for
internal documents, marketing and media. I understand that image/s may be used for publicity
literature, websites, television/radio transmissions or videos that seek to promote our work. I
also understand that we will not receive any financial reward for the use of image(s).
Date:
Young Person’s Signature:
Parent / Carers Signature:
(for participants under 18yrs old)
Events–
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Activity
Activity
Activity
Activity
Activity
1:
2:
3:
4:
5:
Photography workshops
Graffiti workshops
Bike riding & picnic
Horse riding
First Aid Stick-It Workshop
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When –
 Activity 1: Tuesday 5th August, 11:30am - 3pm & Friday
8th August 11:30am - 2pm
 Activity 2: Tuesday 12th, Wednesday 13th and Friday 15th
August 10am – 2.30pm each day
 Activity 3: Tuesday 19th August, 10am – 2pm
 Activity 4: Friday 22nd August, 10am – 1.30pm
 Activity 5: Thursday 28th August, 11am – 3pm
All young people will be met at The Well Centre and
returned back with staff after each activity.
Please wear comfortable clothing and trainers for bike
riding, horse riding and first aid.
Activities are run on a first come first served basis,
please return your consent form as soon as possible to
avoid disappointment. If we do not receive your consent
form before the activity you will be unable to attend.
Youth Workers contact details are –
Charlotte Savyell: 07788 491 063, Claire Devlin: 07885
913 590 or Well Centre 020 8473 1584.
PLEASE COMPLETE AND RETURN TO YOUR YOUTH WORKER OR DROP IT
INTO THE WELL CENTRE – 16 WELLFIELD RD, STREATHAM, SW16 2BP.
You will be contacted before the activity so we can confirm attendees on
the day 