Young Person Emergency Contact FormPlease 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.Please enable JavaScript in your browser to complete this form.Details of Young PersonThis form should be completed by a young person aged 13 years or over or by their legal guardian.Full Name of Young Person *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMaleFemaleEthnicity/NationalityWhite BritishWhite Gyspy or Irish TravellerWhite EuropeanOther White BackgroundBlack BritishBlack AfricanBlack CaribbeanBlack OtherAsian BritishAsian IndianAsian PakistaniAsian BangladeshiAsian ChineseAsian OtherWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed or Multiple ethnic backgroundSchool or CollegeAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeEmail Address *Emergency Contact DetailsThese details will be used to keep you safeFull name of Parent (Or person with Parental Responsibility) *FirstLastAddress if Different from AboveAddress Line 1Address Line 2CityState / Province / RegionPostal CodeEmergency Phone - Mobile *Relationship to young person (Mother, Father, Aunt etc) *Emergency Phone - HomeEmergency Phone - Work or OtherEmailHealth and WellbeingIf you have any allergies / dietary requirements,m ongoing medical requirements, disabilities or impairments please provide details in this boxHealth and WellbeingFurther DetailsAre you currently receiving any other support from The Door?Telephone SupportI have a mentorSomething elseWhich 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.GDPR Agreement (Required to Submit Form) * I consent to The Door storing and processing my personal information for use in connection with my safety or the safety of others. I understand that it may also be used on anonymised basis for the purposes of monitoring and improving The Door’s services.Submit