Youth Group - Involvement Service CiCC

1. Young Persons Name:

(Required)

2. Young Persons Age:

(Required)

3. Young Persons Date of Birth:

(Required)

4. Does the young person take any medication?

5. Will the young person need to take any medication on site?

(Required) Yes No

If Yes please give details

6. Does the young person have any dietary needs?

(Required) Yes No

If yes please give details

7. Does the young person go to mainstream school?

(Required) Yes No

We use this to judge how the young person will integrate into a group environment. If No please give details. All this means is that we will contact you on how to best support the young person

8. Is the young person allergic to anything? (food, meds, etc)

(Required) Yes No

If yes please give details

9. Is there anything we need to know about the child or young person to allow them to fully engage SAFELY in Youth Group? This MUST include any risks, behavioural needs, Accessibility needs, Dietary Needs, Religious needs or Religious considerations. This is to keep everyone safe including the young person, other young people and staff members. (Please use the text box to give us as much information as possible).

(Required) Running Away Neurodiversity Substance and alcohol use Verbal abuse Harmful sexual behaviour (including any allegations) Violence Self harm Fears or phobias Bullying and/or coercion Stealing/offending Arson Travel sickness Issues with staff Restricted contact with siblings/birth family Other NONE

Additional Information:

10. If any concerns are raised I understand that I will be contacted and asked to be part of a risk assessment activity. It may be that Youth Group is not suitable for every young person; if we do not feel that we can keep everyone safe with control measures in place we may not invite the young person to attend.

(Required) Yes - I understand No - please contact me

11. Do you think we need to speak with the child/young persons allocated Social Worker for any additional information?

(Required) Yes No I am the Social Worker

Youth Group - Involvement Service CiCC

Booking information Young Person