Complete a Project Consent Form

“*” indicates required fields

Please complete this short form to provide Streetwise with the necessary consent to support your participation in any Streetwise activities:

Streetwise sometimes needs to share personal and sensitive information (e.g. name, date of birth, postcode) with other organisations who fund our work. We will only share this information with reputable organisations and when it is necessary to do so. I agree that Streetwise can share relevant information about my child with reputable organisations as outlined above.

Details of young person

Name*

Date of Birth*

Gender*

Gender – if not listed above

Address*

Street Address Address Line 2 City County Post Code

Email Address (by providing an email address you consent to us contacting you by email)*

Phone Number (by providing a phone number you consent to us contacting you by text or phone call)

Emergency Contact information

Name of Emergency Contact*

Relationship of Emergency Contact to young person*

Emergency Contact mobile phone number*

Emergency Contact other phone number*

Medical information

Do you / the young person have any medical issues/ allergies that we should be aware of?*

If yes, please detail what these conditions/ allergies are, including any medication if relevant*

Does the young person have a disability we should be aware of? If yes, please provide details*

Please detail their disabilities and any adjustments we might need to consider making*

Hidden

No*

Swimming Capability (for water based activities)*

As part of its work, Streetwise needs to collect and store sensitive personal information about service users. In order to do so, the law on data protection requires Streetwise to receive your explicit consent. Explicit Consent: I hereby consent to Streetwise collecting and storing sensitive personal information about my dependant concerning the support, advice and / or counselling that they receive when accessing Streetwise’s services. The sensitive personal information that Streetwise will collect and store will include; name, date of birth, address, residential, marital, ethnicity, medical details concerning my mental and physical health, and emotional wellbeing (where relevant). I understand that any sensitive personal information collected and stored by Streetwise will: • Be retained for a minimum of eight (8) years after support / counselling has ceased • Be processed in accordance with the 2023 Privacy Notice, which I have read and understood. By signing this consent form, I confirm and understand that: • Confidentiality has been explained to me and I agree that my dependant’s sensitive personal information can be shared with others where another person or my dependant is at risk of significant harm • Sensitive personal information about my dependant can be collected and stored securely by Streetwise, and I understand that such information can be seen by other workers within Streetwise • With my prior explicit consent, my dependant’s sensitive personal information can be shared with others outside of Streetwise • I will contact Streetwise if my dependant cannot make an appointment that has been made for them • If referred by someone else, Streetwise may inform the referrer when counselling and / or support comes to an end • My dependants’ rights at Streetwise, including how to make a complaint and what rights they have in relation to their sensitive personal information, have been explained to me • I may withdraw my consent to Streetwise collecting and processing my dependant’s sensitive personal data at any time I have read and understood the above and give my explicit consent to Streetwise collecting and storing mine and my (dependants) sensitive personal information in accordance with the 2023 Privacy Notice:*

Storing Personal/sensitive information

Sharing personal/sensitive information

Name of Trip/ Activity*

Date of Trip / Activity

I give permission for me (if aged over 16) / my child to attend the project

I give permission for me (if aged over 16) / my child to attend the Trip/ Activity

I give permission for me (if aged over 16) / my child to receive emergency medical treatment in the event of an accident

Please note that the project is Open Access which means that the young person is free to come and go during sessions.

I give permission for the use of photos or other media featuring me / my child

I give permission to receive emails from Streetwise, including via electronic email distribution channels

We may take photos and use recording devices e.g. video cameras for use of display, publicity and project evaluation. These may be passed on to partner organisations during joint events etc. I agree for my child to be in photos and recorded material, to be used for displays, publicity and evaluation reasons. I also agree for photos and recorded material to be shared for publicity and promotional use.

“*” indicates required fields

Please complete this short form to provide Streetwise with the necessary consent to support your participation in any Streetwise activities:

Details of young person

Name*

Date of Birth*

Gender*

Gender – if not listed above

Address*

Street Address Address Line 2 City County Post Code

Email Address (by providing an email address you consent to us contacting you by email)*

Phone Number (by providing a phone number you consent to us contacting you by text or phone call)

Emergency Contact information

Name of Emergency Contact*

Relationship of Emergency Contact to young person*

Emergency Contact mobile phone number*

Emergency Contact other phone number*

Medical information

Do you / the young person have any medical issues/ allergies that we should be aware of?*

If yes, please detail what these conditions/ allergies are, including any medication if relevant*

Does the young person have a disability we should be aware of? If yes, please provide details*

Please detail their disabilities and any adjustments we might need to consider making*

Hidden

No*

Swimming Capability (for water based activities)*

Storing Personal/sensitive information

Sharing personal/sensitive information

Name of Trip/ Activity*

Date of Trip / Activity

I give permission for me (if aged over 16) / my child to attend the project

I give permission for me (if aged over 16) / my child to attend the Trip/ Activity

I give permission for me (if aged over 16) / my child to receive emergency medical treatment in the event of an accident

Please note that the project is Open Access which means that the young person is free to come and go during sessions.

I give permission for the use of photos or other media featuring me / my child

I give permission to receive emails from Streetwise, including via electronic email distribution channels

Details of young person

Emergency Contact information

Medical information

Details of young person

Emergency Contact information

Medical information

Donations to Streetwise

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