Vybz Youth Hub Registration
Young Person's Details
First Name
Last Name
Age
Birthdate
Gender
Please select...
Female
Male
Agendered
Genderfluid
Genderqueer
Gender non-conforming
Intersex
Non-binary
Third gender
Other
Pronouns
Please select...
she/her
he/him
they/them
other
Email
Contact Number
This should be the young person's contact number.
x
Address 1
Address 2
Town / City
Postcode
Parent / Guardian Details
Guardian Full Name
Contact Number
This should be the young person's contact number.
x
Email
Address 1
Address 2
Town / City
Postcode
Page 2
Photo / Video Consent
Do you consent to be included in photos and videos at the Youth Hub and to allow for these to be used for marketing, social media and to be displayed at / by YMCA London City and North?
Please select...
Yes I consent
No I don't want to be included
School / College / University
Name of organisation
What Is Your Main Reason For Registering?
Main interest or reason for coming
Please select...
Connecting with arts, culture and heritage
Creativity and fun
Improving my health and wellbeing
Creating more healthy and safe relationships
Connecting with my identity and belonging
Developing new skills
Additional details
Ethnic Origin
Please select...
Arab
Asian/Asian British: Bangladeshi
Asian/Asian British: Indian
Asian/Asian British: Other
Asian/Asian British: Pakistani
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Other
Chinese/Other ethnic group:Chinese
Chinese/Other ethnic group: Other
Gypsy/Irish Traveller
Kurdish
Mixed: White & Asian
Mixed: White & Black African
Mixed: White & Black Caribbean
Mixed: Other
Pashtun
Persian
White: British
White: Irish
White: Other
Religion
Please select...
Buddhist
Christian (all denominations)
Hindu
Jewish
Muslim
Sikh
Any other religion
Not sure
No religion
Sexual Orientation
Please select...
Asexual
Bisexual
Cetero
Heterosexual
Homoflexible
Homosexual
Lesbian
Other
Pansexual
Unsure
Considers themselves to be transgender
Please select...
Yes
No
Don't know
Emergency Contact Details
Contact 1:
Relationship to young person
Please select...
Friend
Parent / Guardian
Relative
Other
Emergency Contact Name
Contact Number
Contact 2:
Relationship to young person
Please select...
Friend
Parent / Guardian
Relative
Other
Second Contact Name
Second Contact Number:
Page 3
Medical Information
First Aid Consent
Please select...
Yes
No
Health Conditions
If the young person has any health conditions please provide details here.
Allergies
If the young person has any allergies please provide details here.
Medication
If the young person takes medication please provide details here.
Disabilities
If the young person has any disabilities please provide details here.
Other
If the young person has anything else it would be helpful to share please detail here.
Declaration
I hereby declare that all the information given above is true and correct to the best of my knowledge. I also declare that I will abide by the rules and regulation of the VYBZ Youth Hub and I will not be involved in any anti-social or violent behaviour.
I have read and agree to the above declaration
Contact Information