Youth Club Membership Form

Ask a staff member for help if needed. To comply with our safeguarding policy, please complete all sections of this form. Your details will only be used to contact you about the Club and will not be shared with third parties. As a member of PYC, you’ll participate in supervised activities, games, and learning, with potential trips and social events. Members must follow Club rules listed at the end of this form. We are transitioning to a new data system, so all member details are being updated.

Member Details

Name(Required)

First Last

Nickname

Date of Birth(Required)

Phone

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Parent/Carer Details

Name(Required)

Relationship to Member(Required)

Phone(Required)

Email(Required)

Additional/Emergency Contact

Name(Required)

Relationship to Member(Required)

Phone(Required)

Email(Required)

Medical Details

Name of Doctor's Surgery(Required)

Details of any disability, special needs, allergy, dietary requirements or medication (write N/A if none)(Required)

Consent

I consent to the above named member being able to take part in activities arranged by the Purfleet Youth Club and confirm that I am responsible for my child’s safety and behaviour whilst travelling to and from the youth club.

I am happy for my child to walk to and from the Club on their own

I will pick my child up from the Club

I consent that photographs and videos taken of my child while participating in PYC activities may be used in display and promotion of the youth club in print and online media.

I also give consent for access of educational information and other youth services as appropriate.

If I do not agree to let my child participate fully in youth club activities, the youth club may in the interest of the group decide not to involve my child on a particular “activity”, I have read and understood the PYC rules and will ensure that my child abides by them.

Signature(Required)

Name(Required)

Date(Required)

Youth Club Membership Form

Member Details

Parent/Carer Details

Additional/Emergency Contact

Medical Details

Contact

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