Halton Youth Cabinet
Young Person's Details
Young Person's Forename
Young Person's Surname
Young Person's Date of Birth
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Address 1
Address 2
Town
County
Post Code
Ward
Please Select
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 Select
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 Select
Buddhist
Christianity
Hindu
Jewish
Muslim
No religion affiliation or belief
Prefer Not to Say
Do you have a disability? Please select all that apply
Sensory Impairment
Physical Impairment
Learning Disability or Cognitive Impairment
Mental Health Condition
Long-standing illness or health condition
Other
N/A
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 Select
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 Select
Parent
Carer
Guardian
Other
Consent for activities
Consent to take part in Vibe Climbing Wall
Please Select
Yes
No
Consent
Please confirm by ticking the options below if you would like to grant consent for the young person to attend various Vibe activities
Consent to attend Vibe Events
Consent to attend Vibe Outdoors
Consent to attend Vibe Skate Park
Consent to attend Vibe Youth Club
Consent to take part in Vibe Climbing Wall
None of the above
Please confirm by ticking the options below if you would like to grant consent for the young person's image to be used
Consent for image to be used within Vibe
Consent for image to be used on Vibe social media
Consent for image to be used in any media should the opportunity arise
Consent for image to be used in Vibe printed publications
None of the above
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
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
Submit