Emergency Contact Form -

Young Person Emergency Contact Form

Please complete this form for every young person that is going to attend one of The Door's Youth Clubs. This form can also be used to update existing information about a young person.

Details of Young Person

This form should be completed by a young person aged 13 years or over or by their legal guardian.

Full Name of Young Person *

First

Last

Date of Birth *//

Sex

Ethnicity/Nationality

School or College

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email Address *

Emergency Contact Details

These details will be used to keep you safe

Full name of Parent (Or person with Parental Responsibility) *

First

Last

Address if Different from Above

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Emergency Phone - Mobile *

Relationship to young person (Mother, Father, Aunt etc) *

Emergency Phone - Home

Emergency Phone - Work or Other

Health and Wellbeing

If you have any allergies / dietary requirements,m ongoing medical requirements, disabilities or impairments please provide details in this box

Health and Wellbeing

Further Details

Are you currently receiving any other support from The Door?

Telephone Support
I have a mentor
Something else

Which youth club do you / are you planning to attend?

Where did you find out about The Door's youth clubs?

Photo Consent (Optional)

I give my consent for photos and videos of the young person named above to be taken by The Door whilst participating in The Door’s activities, and for The Door to use these photos/videos in their fundraising and publicity.