National Citizen Service
Programme Consent Form
STAFF USE:
EOI form completed*
Enrolment form completed*
Contact Information
First name
________________________
Surname
_________________________
Primary Emergency Contact
Secondary Emergency Contact
Name
______________________
Name
______________________
Relationship
______________________
Relationship
______________________
Daytime tel.
______________________
Daytime tel.
______________________
Evening tel.
______________________
Evening tel.
______________________
Address 1
______________________
Address 1
______________________
Address 2
______________________
Address 2
______________________
Postcode
______________________
Postcode
______________________
Medical Information
Name of GP
________________________
Telephone
________________________
Address
________________________
________________________
Can you swim 50 metres unaided?
Yes
Date of last anti tetanus injection
No
__ __ / __ __ / __ __ __ __
Do you have any dietary needs?
Yes
No
If yes please detail:
Do you have any allergies or medical problems?
Yes
No
If yes please detail:
Have you been in contact with any infectious illnesses in the last 21 days?
Yes
No
If yes please detail:
Are you currently taking any form of medication?
Yes
No
If yes please detail the name, dose and frequency of the medication:
NOTE: Additional notes on your health or diet which may require treatment or special
attention but which is not sufficient to prevent you joining the programme must be stated
below. This should include particular activities which may form part of the programme in
which you should not participate for health reasons:
Media & Photographic Consent
National Citizen Service is all about celebrating young people doing great things in their communities.
An important part of this will involve marketing, press and website work around NCS projects, which
will be brought to life with photographs and film.
Please complete the form below so that we know whether you are happy to appear in the
photographs we use. This includes any images or footage taken by either the local NCS provider, the
Catch22 NCS Partnership, or by external media organisations as sanctioned by us. For any queries
please speak to staff at your local NCS provider.
They will only be used for the purposes listed below for promoting NCS and the work done by the
young people on this programme. Should we wish to use them for other purposes, we will seek your
permission again.
Photographs or film footage may be used for the following purposes.
Please tick all those you are happy with:
External media: this may include newspapers, TV, magazines, internet eg. BBC news
Catch22 NCS website
Catch22 NCS social media: Facebook, Twitter and YouTube pages belonging to NCS
Catch22 NCS Publications: leaflets, posters, event programmes etc.
Government / Cabinet Office publications and website regarding NCS
Local NCS provider publications and website
Other partner organisations: local partners or training providers working with you on NCS
If we use your photograph you can choose to have your real name published with it, choose
only to include your first name, or you can remain anonymous. Tick the one that applies:
Real name
First name only
Anonymous
I am happy to give permission for my photos/film footage/quotes/case study to be used by Catch22
NCS Partnership and it’s local providers.
I pledge to update the Catch22 NCS Partnership and local NCS provider if there are any changes to
any of the information I have given as part of my sign up process.
Signature of Young Person:
__________________________________
Print name:
__________________________________
Date:
__________________________________
Parent / Guardian / Carer Consent
Declaration

I have read the information about the programme and understand that if I have any queries I can
discuss them with the staff from my local NCS provider.

I give my consent to my son/daughter/ward attending the programme, which will include
education, training, residential and on-going practical exercise.

I understand that while my son/daughter/ward is participating in the project they will be subject to
the project’s general code of behaviour and will be required to obey the instructions and advice of
project workers and accompanying adults, otherwise they may be sent home if necessary.

I understand the project will do everything in its control to protect my son/daughter/ward personal
possessions but cannot be held responsible for any loss or damage.

I understand that this NCS programme is covered by the information sharing protocols of my local
NCS provider.

My child is in good health to the best of my knowledge and I consider him/ her fit to take part in
the programme.

*In the event of an accident or illness I understand that every effort will be made to contact me
but, if this is not possible, I authorise the project leader to consent to any medical treatment
including inoculations, surgery or blood transfusions from a qualified medical practitioner which, in
the opinion of the qualified medical practitioner, may be necessary for my child in the course of
the programme, project or offsite activity.

During the course of the activities media coverage and pictures may be taken and used for
publicity purposes. By signing this declaration you are agreeing to this process and are giving
your permission in agreement with the choices made by the named Young Person as stated on
the Media & Photographic Consent portion of this form.
By completing and signing this form, you are agreeing to the named Young Person participating in
NCS 2012.
Signature of Parent / Guardian / Carer
________________________________
Print name:
________________________________
Date:
________________________________
* Note The medical profession takes the view that parents consent to medical treatment cannot be
delegated. This view is explicit in the Child Act 1989. Thus, medical consent forms have no legal
status and a doctor/nurse insisting on a particular treatment has the right to do. However, it can be a
comfort to medical staff to have general consent in advance from parents.