Cumberland Lodge residential

1.  

Name of Young person

2.  

Date of Birth and age of Young person

3.  

Address of Young person

4.  

Young persons phone number

5.  

Young persons e-mail address

6.  

Please give any relevant medical or SEND information for the young person

7.  

First emergency contact name, relationship to Young person and phone number

8.  

Second emergency contact name, relationship to Young person and phone number

9.  

Parent/carer name

10.  

Parent/carer e-mail address

13.  

I consent for photos and videos to be taken and used for relevant promotional materials, social media and other mediums relevant to this trip and subsequent publications.