Registration Form

Young Person's Information

First Name*

Last Name*

Date of Birth*

Ethnicity

___*

YP Mobile*

Street Address 1

Street Address 2

Town / City

Postcode

Gender

Male

Female

___*

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Parent/Carer Information

Name*

Relationship*

Mobile Number*

Home Number

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Emergency Contact if different from above

Name*

Relationship*

Mobile Number*

Home Number

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Select

Education/Employment

Please state which School/College:

Is the young person supported by any other services?

Please Tick all that apply

Social Services: Child Protection

Early Help

Child Adolescent Mental Health Service (CAMHS)

Social Services: Looked After Child

Youth Offending Service (YOS) / Probation

Keyworker/Mentor/Support Worker

If none of these please state other:

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Social worker information

Name*

Mobile Number*

Email*

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Does the young person have learning difficulties / disability / or any medical conditions (Tick Yes or No):

YES

If YES please outline the learning needs of the young person below:

Is there any medication the young person will need to take whilst with us? (Tick Yes or No):*

YES

If YES please outline the learning needs of the young person below:

Are all the young person's vaccinations up to date? (Tick Yes or No):

YES

Allergies/Dietary requirements:

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Tell us a bit about the young person: e.g. other skills, hopes for project, what made them pick this project? Please also detail any Safeguarding and/or Behavioural needs:

How did the you/the young person hear about the project?

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How we use information about the young person

Why we collect and use this information

We use children and young person’s data to:

• enable us to carry out statutory functions for which we are responsible, including safeguarding and welfare of children

• produce statistics and reports which inform decisions made by the council. Statistics are used in such a way that individual children/young people cannot be identified from them.

• evaluate, monitor and review service provision

Personal and Sensitive Information

We collect, process, hold and share the following information:

• personal information (such as name, date of birth, contact details and address)

• characteristics (such as ethnicity, religion and language) [sensitive]

• special education needs information

• relevant medical and health information

• parents/carers contact information

• youth activities participation records

Using media content (photo, video and audio content)

Croydon Council may take photographs, video and audio recordings (media) containing young people throughout the duration of the youth engagement team provision. This media is taken to publicise and record outcomes for the youth engagement team provision and to let young people know about other projects the youth engagement team are delivering. This media may be used in digital and printed publications (including Croydon Council’s website and social media pages) or may appear in local, regional or national media. We will not include any personal information on any digital or printed material.

Consent can be withdrawn at any time (see ‘Withdrawing consent’ section). If consent is withdrawn we will stop using the photos/videos/audio content for future purposes but may not be able to retract publications already in the public domain.

Withdrawing consent

Consent can be withdrawn at any point by unsubscribing from an email or newsletter or by contacting us on youngcroydon@croydon.gov.uk or 07729 445 983.

Young people participating in a programme can withdraw their consent at any point by contacting us; however this may impact their ability to fully participate in the programme.

For more information, including who we may share information with, please see our Privacy Notice which outlines information the Education and Youth Engagement directorate holds and what we do with it. https://www.croydon.gov.uk/democracy/data-protection-freedom-information/privacy-notices/education-youth-engagement-service-privacy-notice

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CONSENT

I give consent for personal and sensitive information about this young person to be collected, processed, held and shared by Croydon Council’s Education and Youth Engagement Team

Consent*

YES

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I give consent for this young person to travel on their own around the borough (Travelling to, from and during sessions).

consent*

YES

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I give consent for this young person to be filmed, recorded and photographed during the programme.

Consent*

YES

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I give consent for Croydon Council’s Education and Youth Engagement Team to send marketing information on upcoming relevant programmes.

Consent*

YES

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Name

Relationship with young person

Signature