Questionaire | Consentform

DAFC Youth Academy

The online form should be completed at the start of every season by the young person (under the age of 18) and/or their parent/carer.

Please review fully the --> attached Document before filling in the form below.
Please review the details and enter information below.

By submitting the form you are providing a signature to the agreements on this form.

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UPDATE: Please can you fill in the details in the system when logged in.
This form is now only used to act as Confirmation that you have supplied the details. Thank You !
Consent Form Season 2024

If the young person is aged 13 and over they should read the information on this form and complete the form with the support of their parent/carer. The young person and their parent/carer should complete sections G and H, respectively. If the young person is aged under 13 then the form should be completed by their parent/carer and section G does not require to be completed.
All information included in this form will be treated with sensitivity and respect and only shared with those require the information to perform their role. The form will be kept in a secure and confidential manner.
If any information contained within this form changes during the course of the season, please let the Head Of Academy know as soon as possible by contacting him at bill@dafc.co.uk

A. General Information
NAME

DATE OF BIRTH

ADDRESS

POSTCODE

EMAIL

TELEPHONE

MOBILE

B. Medical Information
NAME OF GP

MEDICAL ADDRESS Address

MEDICAL POSTCODE

MEDICAL TELEPHONE

DISABILITY 1. Do you have a disability that will affect your ability to take part in football ?
    No     Yes

DISABILITY INFO If yes, please give details:

MEDICAL CONDITION 2. Do you have a medical condition that will affect your ability to take part in football ?
    No     Yes

MEDICAL CONDITION INFO If yes, please give details:

MEDICATION 3. Do you take any medication ?
    No     Yes

MEDICATION INFO If yes, please give details:

INJURIES 4. Do you have any existing injuries ?
    No     Yes

INJURIES INFO If yes, please give details:

ALLERGIES 5. Do you have any allergies, including allergies to medication ?
    No     Yes

ALLERGIES INFO If yes, please give details:

OTHER 6. Is there any other relevant information which you would like us to know? (e.g. access rights, disabilities, special dietary requirements etc)
    No     Yes

OTHER INFO If yes, please give details:

C. Sharing Information
Children and young people and their parents/carers may have access to a Named person to help them get the support they need. A Named Person will normally be the health visitor for a pre-school child and a promoted teacher – such as a Head Teacher or Pastoral Care teacher – for a school age child.
NAME PERSON or Teacher

NAMED TELEPHONE

D. TRANSPORTATION OF CHILDREN AND YOUNG PEOPLE
For the purpose of football activities, the Academy may transport you to and from games, activities or events. The Academy will ask any person using a private vehicle to declare that they are properly licensed and insured and, in the case of a person who cannot so declare, will not permit that individual to transport children and young people.
Full information on the transportation of children and young people can be found in the Academy’s Child Wellbeing and Protection Policy in the Trips and Travel Away Practice Note.
TRANSPORTATION Tick to confirm you have read and agree
Yes No

E. PHOTOGRAPHS AND VIDEOS
You may be photographed or filmed when participating in football. Photographs or videos of you participating as part of the team may be:
a) published in Academy publications, including on the Academy’s website; b) used for training purposes; c) broadcast live over the internet by the Academy. This is commonly known as ‘live streaming’.
All images and videos will be taken and used in line with the Academy’s Child Wellbeing and Protection Policy, full information of which can be found in the Celebration Practice Note.
IMAGES Tick to confirm you have read and agree
Yes No

F. CONTACT INFORMATION
The Academy may contact you via email, text or social networking site with information relating to football activities.
All communication will be done in line with the Academy’s Child Wellbeing and Protection Policy, full information of which can be found in the Communication and Social Media Practice Note.
CONTACT Tick to confirm you have read and agree
Yes No

G. AGREEMENT (to be completed by the young person)
The young person should select options in this section and provide their full name and date of entering.
CONSENT 1 I consent to the Academy storing the medical information I have completed in Section B (Medical Information) of this form the duration of the season
    Yes     No

CONSENT 2 I consent to receiving medical treatment, including anaesthetic, which medical professionals present consider necessary.
    Yes     No

CONSENT 3 I consent to the Academy sharing information with my Named Person or school, as deemed appropriate, if my wellbeing is, or may be, impacted and it is deemed necessary by the Academy Child Wellbeing and Protection Officer to share that information.
    Yes     No

CONSENT 4 I consent to the Academy contacting me via email, text or social media to give me information about football activities.
    Yes     No

YOUNG PERSON NAME

DATE TODAY

H. AGREEMENT (to be completed by the young person’s parents/carers)
The young person should select options in this section and provide their full name and date of entering.
CONSENT 5 I consent to my child receiving medical treatment, including anaesthetic, which the medical professionals present consider necessary.
    Yes     No

CONSENT 6 I consent to the Academy sharing information with my child’s Named Person or school, as deemed appropriate, if the young person’s wellbeing is, or may be, impacted and it is deemed necessary by the Academy Child Wellbeing and Protection Officer to share that information.
    Yes     No

CONSENT 7 I consent to my child being contacted via email, text or social networking site for the purposes as set out on Section F.
    Yes     No

CONSENT 8 I do wish to be copied into these messages.
    Yes     No

CONSENT 9 I confirm that I am aware of the Academy’s Child Wellbeing and Protection Policy and the Academy’s Set the Standards: Behaviours, Expectations and Requirements (Code of Conduct)
    Yes     No

CONSENT 10 I agree to Inform the Academy should any of the information contained in this form change.
    Yes     No

PARENT CARER NAME

RELATIONSHIP to young person

PARENT DATE (date of filling form)

PARENT EMAIL

ADDITIONAL INFORMATION If you do not consent to any of the above, please provide details:

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