ClementJames Young People's Programme

This is a permission form for the chosen young people to participate in group workshops with The ClementJames Centre.

Thank you for taking the time to fill out this form. If you need support filling out this form, please contact reception@clementjames.org or give us a call on 020 7221 8810.

Privacy Notice

At The ClementJames Centre, we're committed to protecting and respecting your privacy.

Please see our privacy notice attached here, and tick to say you have read and understood it and that you agree for your and your child's data to be stored by The ClementJames Centre.

Criteria

The ClementJames Centre is a charity and as such we have certain criteria to access our services. Please tick which of the following apply to your child:

Receiving benefits

Have a household income of less than £25,000

If your child receives free school meals

Living in social housing (this includes council, temporary accommodation or housing association)

N/A

Young Person's Details

Please provide your child's details below:

First Name

Last Name

Date of Birth

Gender

Self-described gender, if known:

Ethnicity

Self-described ethnicity, if known:

Post Code

Guardian Contact Details

Parent/Guardian Contact Number

Parent/Guardian Email

I would like to be added to The ClementJames Newsletter to hear more about the services we offer

YesNo

Please provide details of an emergency contact

Emergency Contact Full Name

Emergency Contact Telephone Number

Permissions

I give permission for my child to leave The ClementJames Centre on their own

YesNo

I give permission for The ClementJames Centre to take photos of my child.

YesNo

I understand that Clement James will pass on any concerns about a young person's safety or wellbeing will be passed on to your child's school

Yes

Accessibility Needs

Does the young person have any physical accessibility needs that we should know about?

Please provide us with more details

Please tick here if the young person will need assistance to exit the building in the event of an emergency evacuation. Staff will prepare a Personal Emergency Evacuation Plan (PEEP) for the young person.

Does the young person have any educational needs that we should know about?

Please provide us with more details

Submit Your Form

Please submit the form below.