Endeavour Consent Form

Each person who takes part in an Endeavour programme can only do so after the completion of an Endeavour Consent and Participation Information Form. This form is to tell us about any needs we should cater for. We try our best to include everyone so please tell us as much information as possible.

A participant is anyone who attends an Endeavour event, this may be:

a child taking part in an Endeavour programme
an adult relative / guardian of a child taking part in an Endeavour programme
an adult taking part in an Endeavour programme
an adult taking part in an Endeavour event.

This form should be completed by and signed by an adult (a person aged 18 or over).

What Consent Means

That you consent to yourself/your child taking part in an Endeavour programme including all related activities.
That you are happy for yourself/your child to use travel & transport provided by Endeavour.
That you/your child does not suffer from a medical or physical condition which would preclude them from participation.
That you/your child will follow all safety guidelines given by staff.
That you/your child may receive first aid or medical treatment if necessary during an Endeavour programme.
That you recognise that a small degree of risk exists in all activities.
That you have provided us with accurate information about yourself/your child and will inform us of any changes.
Should further support be required, that you are happy for Endeavour to arrange for outside agencies, other professionals or other providers to work with you/your child as appropriate.
That you acknowledge that whilst on an Endeavour programme, you/your child is advised to not bring any valuables with you/them, and that Endeavour is not responsible should you/your child bring anything of value that is lost, damaged or stolen.

You/Your child should expect

To be responsible for your/their own behaviour whilst on an Endeavour Programme. You/they should follow all instructions including but not limited to behaviour, health and safety, and respect.
To remain with the programme, you/they should not leave the programme/project site without informing a member of staff.
To be open and transparent with staff. You/they must report any accidents, illness or discomfort to staff immediately.

Tetanus

We strongly advise that you/your child’s tetanus protection is up-to-date.

Where we rely on your consent to use you/your child’s personal information, you have the right to withdraw that consent at any time. This includes the right to ask us to stop using personal information for direct marketing purposes, to be unsubscribed from our email list at any time, to withdraw permission for your own/your child’s images to be used for social media and publicity materials and/or academic evidence. A full copy of our privacy policy is available. If you change your mind and no longer wish to give consent then please inform us in writing at: info@endeavour.org.uk or by calling us on 0114 243 8219.

By signing below, you consent to you/your child taking part in Endeavour Programmes and to receiving any first-aid or urgent medical treatment required during the Programmes. You confirm that you have read and understood the information about Endeavour (above). You also agree to the information about you/your child being shared with partner organisations involved in the delivery and support of this programme.

I consent to the information above

Yes

If you are unable or unwilling to consent to the information above this form cannot be completed. For further assistance please contact info@endeavour.org.uk or call us on 0114 2438219.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

Postcode

Contact phone number

Signature

Sign Here

Date

I am...

a participant over the age of 18 who is signing on behalf of myself

a parent/legal guardian, signing on behalf of myself and/or my child(ren)

a third party signing on behalf of a parent/guardian with permission

What is your relationship to the participant/s?

As a parent/guardian/third party, are you personally participating in Endeavour programmes/activities?

Yes

How many children are you giving consent for?

If you wish to provide consent for 5 or more children please do not continue with this online form. Please contact us on info@endeavour.org.uk or call 0114 243 8219 for further information on how to provide consent for larger groups.

Next of Kin / Emergency Contact Details

Please provide us with the following information so that we know who we should contact in the event of an emergency. If you and your children are taking part in an Endeavour programme (or you are an adult taking part in an Endeavour programme/event), you must provide the details of someone else who is not on the programme/event who we can contact.

Preferred name

Relationship to you/your child

Contact number

2nd emergency contact preferred name

2nd emergency contact relationship to you/your child

2nd emergency contact number

2nd emergency contact email

Your details

Gender

Female

Male

Non-binary

Prefer not to say

Other

Please specify gender

Date of birth

Do you have any additional support needs (eg SEN)?

Yes

Please specify additional support needs

Clothing size

Adult S

Adult M

Adult L

Adult XL

Child S

Child M

Child L

Child XL

Other

Please specify clothing size

Shoe size

Medical Information

GP Surgery

Do you have any of the following? (tick all that apply)

Allergies

Asthma

Diabetes

Epilepsy

Do you have any past injuries/illnesses that we may need to be aware of or make adjustments for?

Yes

Please provide details of past injuries/illnesses

Do you have any disabilities or access needs that we may need to be aware of or make adjustments for?

Yes

Please provide details of disability or access needs

Do you suffer from travel sickness?

Yes

Do you take any medication for travel sickness?

Yes

Do you take any routine medication?

Yes

Please provide details of routine medication

Does the participant have an individual health care plan /response plan If so, please return it with this form / email it to consent@endeavour.org.uk

Yes

Additional Needs

Please provide details for any of the following that may apply:

Your first language

Faith requirements

Dietary requirements

Visual aids or support needs

Hearing aids or support needs

Examination access needs

Could you be pregnant?

Yes

Please provide details of any support or adjustment needs you may have

Any other professionals or services involved

Is there anything else we should know to support you?

Child 1 details

First Name

Last Name

Child 1 gender

Female

Male

Non-binary

Prefer not to say

Other

Please specify Child 1 gender

Child 1 Date of birth

Please state where the child/participant lives.

Address Line 1

Address Line 2

City

State

Zip Code

Country

Does Child 1 have any additional support needs (eg SEN)?

Yes

Please specify additional support needs for Child 1

Child 1 clothing size

Adult S

Adult M

Adult L

Adult XL

Child S

Child M

Child L

Child XL

Other

Medical Information

Child 1 GP Surgery

Does Child 1 have any of the following? (tick all that apply)

Allergies

Asthma

Diabetes

Epilepsy

Does Child 1 have any past injuries/illnesses that we may need to be aware of or make adjustments for?

Yes

Please provide details of past injuries/illnesses for Child 1

Does Child 1 have any disabilities or access needs that we may need to be aware of or make adjustments for?

Yes

Please provide details of disability or access needs for Child 1

Does Child 1 suffer from travel sickness?

Yes

Does Child 1 take any medication for this?

Yes

Does Child 1 take any routine medication?

Yes

Please provide details of routine medication for Child 1

Does Child 1 have an individual health care plan /response plan If so, please return it with this form / email it to consent@endeavour.org.uk

Yes

Additional Needs

Please provide details for any of the following that may apply:

Child 1 first language

Child 1 faith requirements

Child 1 dietary requirements

Child 1 visual aids or support needs

Child 1 hearing aids or support needs

Child 1 examination access needs

Could Child 1 be pregnant?

Yes

Please provide details of any support or adjustment needs Child 1 may have

Any other professionals or services involved with Child 1

Is there anything else we should know to support Child 1?

Child 2 details

First Name

Last Name

Please specify Child 2 gender

Child 2 gender

Female

Male

Non-binary

Prefer not to say

Other

Child 2 Date of birth

Please state where the child/participant lives.

Address Line 1

Address Line 2

City

State

Zip Code

Country

Does Child 2 have any additional support needs (eg SEN)?

Yes

Please specify additional support needs for Child 2

Child 2 clothing size

Adult S

Adult M

Adult L

Adult XL

Child S

Child M

Child L

Child XL

Other

Please specify clothing size for Child 2

Child 2 shoe size

Medical Information

Child 2 GP Surgery

Does Child 2 have any of the following? (tick all that apply)

Allergies

Asthma

Diabetes

Epilepsy

Does Child 2 have any past injuries/illnesses that we may need to be aware of or make adjustments for?

Yes

Please provide details of past injuries/illnesses for Child 2

Does Child 2 have any disabilities or access needs that we may need to be aware of or make adjustments for?

Yes

Please provide details of disability or access needs for Child 2

Does Child 2 suffer from travel sickness?

Yes

Does Child 2 take any medication for travel sickness?

Yes

Does Child 2 take any routine medication?

Yes

Please provide details of routine medication for Child 2

Does Child 2 have an individual health care plan /response plan If so, please return it with this form / email it to consent@endeavour.org.uk

Yes

Additional Needs

Please provide details for any of the following that may apply:

Child 2 first language

Child 2 faith requirements

Child 2 dietary requirements

Child 2 visual aids or support needs

Child 2 hearing aids or support needs

Child 2 examination access needs

Could Child 2 be pregnant?

Yes

Please provide details of any support or adjustment needs Child 2 may have

Any other professionals or services involved with Child 2

Is there anything else we should know to support Child 2?

Child 3 details

First Name

Last Name

Child 3 gender

Female

Male

Non-binary

Prefer not to say

Other

Please specify Child 3 gender

Child 3 Date of birth

Please state where the child/participant lives.

Address Line 1

Address Line 2

City

State

Zip Code

Country

Does Child 3 have any additional support needs (eg SEN)?

Yes

Please specify additional support needs for Child 3

Child 3 clothing size

Adult S

Adult M

Adult L

Adult XL

Child S

Child M

Child L

Child XL

Other

Please specify clothing size for Child 3

Child 3 shoe size

Medical Information

Child 3 GP Surgery

Does Child 3 have any of the following? (tick all that apply)

Allergies

Asthma

Diabetes

Epilepsy

Does Child 3 have any past injuries/illnesses that we may need to be aware of or make adjustments for?

Yes

Please provide details of past injuries/illnesses for Child 3

Does Child 3 have any disabilities or access needs that we may need to be aware of or make adjustments for?

Yes

Please provide details of disability or access needs for Child 3

Does Child 3 suffer from travel sickness?

Yes

Does Child 3 take any medication for travel sickness?

Yes

Does Child 3 take any routine medication?

Yes

Please provide details of routine medication for Child 3

Does Child 3 have an individual health care plan /response plan If so, please return it with this form / email it to consent@endeavour.org.uk

Yes

Additional Needs

Please provide details for any of the following that may apply:

Child 3 first language

Child 3 faith requirements

Child 3 dietary requirements

Child 3 visual aids or support needs

Child 3 hearing aids or support needs

Child 3 examination access needs

Could Child 3 be pregnant?

Yes

Please provide details of any support or adjustment needs Child 3 may have

Any other professionals or services involved with Child 3

Is there anything else we should know to support Child 3?

Child 4 details

First Name

Last Name

Child 4 gender

Female

Male

Non-binary

Prefer not to say

Other

Please specify Child 4 gender

Child 4 Date of birth

Please state where the child/participant lives.

Address Line 1

Address Line 2

City

State

Zip Code

Country

Does Child 4 have any additional support needs (eg SEN)?

Yes

Please specify additional support needs for Child 4

Child 4 clothing size

Adult S

Adult M

Adult L

Adult XL

Child S

Child M

Child L

Child XL

Other

Please specify clothing size for Child 4

Child 4 shoe size

Medical Information

Child 4 GP Surgery

Does Child 4 have any of the following? (tick all that apply)

Allergies

Asthma

Diabetes

Epilepsy

Does Child 4 have any past injuries/illnesses that we may need to be aware of or make adjustments for?

Yes

Please provide details of past injuries/illnesses for Child 4

Does Child 4 have any disabilities or access needs that we may need to be aware of or make adjustments for?

Yes

Please provide details of disability or access needs for Child 4

Does Child 4 suffer from travel sickness?

Yes

Does Child 4 take any medication for travel sickness?

Yes

Does Child 4 take any routine medication?

Yes

Please provide details of routine medication for Child 4

Does Child 4 have an individual health care plan /response plan If so, please return it with this form / email it to consent@endeavour.org.uk

Yes

Additional Needs

Please provide details for any of the following that may apply:

Child 4 first language

Child 4 faith requirements

Child 4 dietary requirements

Child 4 visual aids or support needs

Child 4 hearing aids or support needs

Child 4 examination access needs

Could Child 4 be pregnant?

Yes

Please provide details of any support or adjustment needs Child 4 may have

Any other professionals or services involved with Child 4

Is there anything else we should know to support Child 4?

Photo Permissions

I give permission for photographs and videos taken of myself / my children at Endeavour to be used on Endeavour social media and publicity materials

Yes

I give permission for photographs and videos taken of myself / my children at Endeavour to be shared with partner organisations and funders, which may be used on their social media and publicity materials

Yes

I give permission for photographs and videos taken of myself / my children at Endeavour to be used in academic evidence which may go to external moderators

Yes

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country