Vibe Outdoors in Brown's Field
Young Person's Details
Young Person's Forename
Young Person's Surname
Young Person's Date of Birth
Address 1
Address 2
Town
Post Code
Name of school
Contact
Young Person's Telephone
Young Person's Mobile
Young Person's Email
Demographic
Gender
Please choose a value
Female
Male
Non-Binary
Ethnicity
Please choose a value
White British
White Irish
White Traveller of Irish Heritage
White Gypsy/Roma
White Other
Mixed White & Black Caribbean
Mixed White & Black African
Mixed White & Black Asian
Mixed Other
Black British
Black African
Black Somali
Black Caribbean
Black Other
Asian British
Asian Bangladeshi
Asian Pakistani
Asian Indian
Other Vietnamese
Other Chinese
Other
Prefer Not to Say
Religion
Please choose a value
Buddhist
Christianity
Hindu
Jewish
Muslim
No religion affiliation or belief
If yes, please select all that apply
Sensory Impairment
Physical Impairment
Learning Disability or Cognitive Impairment
Mental Health Condition
Long-standing illness or health condition
Other
If other, please specify
Groups - Please tick any that apply
EHC plan
Emotional health concerns
Have a social worker
Living in temporary housing
NEET
None
Receive pupil premium (free school meals)
SEND
Young carer
Medication
Do you take any medication?
Please choose a value
Yes
No
If yes, please give detail
Emergency Contact
Full Name of parent/carer/guardian
Address
Postcode
Email of Parent/Carer/Guardian
Telephone
Mobile
Relationship to Contact
Please choose a value
Parent
Carer
Guardian
Other
Consent
Consent for Filming and Photography
I have parental/guardian responsibility for and give my consent for the images and/or case study of the child named above to be used in any of the following:
• Websites - use on Vibe website
• Websites - use on external/partner websites
• Publications – use in regional or national media or Vibe promotional material.
• Radio Interviews – to be broadcast on regional or national radio.
• Filming – to be show inside or outside of Vibe, including regional or national television.
I understand that if I wish this consent to be withdrawn I should contact the Marketing and Communications Team in writing via hello@vibeuk.org and they will remove my images and any information about me from their records. However, I understand that the material to be produced today is intended for public circulation and/or for publication in the mass media therefore withdrawal of content which has already been circulated publically may not be possible.
Where photographers and filmmakers are involved from outside of Vibe I understand that Vibe has no control over how these images may be used by external parties/media in the future. I accept the conditions of this agreement:
Yes
No
Full name of person providing consent
E-mail for person providing consent:
Clear
Consent to attend Vibe Activities
By ticking this box you agree you have parental/guardian responsibility for the above-named child and agree that they can take part in the above activities.
Vibe activities are supervised by qualified youth workers, However, accidents can happen. Vibe can accept no liability for injuries sustained or any other loss, howsoever caused, in the absence of the negligence of Vibe or its
employees.
Yes
No
Full name of person providing consent
Relationship to Participant
Parent
E-mail for person providing consent:
Clear
Submit