Impact Registration Form

Hi Parents/Carers!
Impact Youth is a secondary-school-age youth club run in the Ainsdale area, usually every Wednesday in term time – 4.30pm-6pm.

It is run on behalf or Churches Together in Ainsdale and managed by Linda Davies (previous teacher at Ainsdale St John’s), other local volunteers, plus Tabz and Simon, the youth workers from the charity, Southport & Area Schools Worker Trust, who see it as a continuation of their Safe Space project in primary schools and secondary schools right across Southport.

Please fill out this form below if a child in your care wishes to join Impact Youth so that we can give you up-to-date information about how things are running make sure we have all the right consent.

Thanks! Your Impact Youth consent form was submitted.
We’ll be in touch if we need anything else.

Name of young person:

Date of birth:

Address:

Any allergies, medical conditions or additional needs that we should be aware of:

Parent or Carer's Name:

Relationship to child:

Contact Phone Number (in case of emergencies):

Email Address (to let you know of any news and info):

I consent for my child to take part in Impact and for the contents of this form to be securely kept by Southport and Area Schools Worker Trust. I allow them to contact me on the number and email address when required.
I agree

Photographic Consent:

I allow my child’s image to be used to promote SASWTrust and/or Impact Youth.I don’t allow my child’s image to be used to promote SASWTrust and/or Impact Youth.

Arrival and Departure from the youth club:

My child is responsible for their journeys to and from Impact.A suitable adult will always drop off and collect my child

Signature: