Leisure & Culture Dundee - Parental Consent Form

Please complete a separate form for each individual child. Compulsory data is indicated by *

PARTICIPANT DETAILS
Child Forename *
Child Surname *
Gender * Male Female
Date of birth * (dd-mm-yyyy, e.g. 01-01-2000)
Address *
Town *
Postcode *
Email Address *
PARENT/GUARDIAN DETAILS
Title *
Parent Forename *
Parent Surname *
Date of birth * (dd-mm-yyyy, e.g. 01-01-1970)
Address *
Town *
Postcode *
Telephone No. *
Mobile No.
Email Address *
EMERGENCY CONTACT & CHILD UPLIFT
Children under 8 years MUST be signed out by an authorised adult (over 18yrs). Please
give names of up to 2 emergency contacts who can be contacted (if the parent/guardian/carer
is unreachable) and are also authorised to uplift your child from the class/activity.
Person 1
Name *
Telephone No. *
Person 2
Name *
Telephone No. *
I hereby grant permission for my child to leave the LACD session on their own. I accept that
LACD have the right to refuse any child to leave on their own should a risk to their safety or
well-being be identified. (Please tick if appropriate)
MEDICAL INFORMATION
Please detail any medical conditions, including allergies which your child has. *
Please detail any medication that your child may require to carry and/or self administer. *
NOTE: If your child requires to carry an EpiPen in case of anaphylactic shock,
you must detail this in the above spaces and meet the activity leader on the first day
of the session. Parents must meet the activity leader at the session to demonstrate
the use of EpiPen.
ADDITIONAL SUPPORT
Please detail any additional support required. *
Please detail if your child will require support from a parent/guardian/carer during the class. *
Yes No Please indicate if your child is prone to travel or motion sickness.*
SWIMMING ABILITY
Yes No Able to swim 1 length unaided (25 metres) *
Yes No Confident in deep water *
SNOW SPORT
For snow sport courses please provide the following information.
Height
Weight
Shoe Size
PHOTO CONSENT
Leisure & Culture Dundee are committed to providing quality, safe programmes and activities for all
participants through the effective implementation of policy.

It is the responsibility of the parent/guardian/carer to ensure the safe drop off and collection
of children at all Leisure & Culture Dundee classes/activities in accordance with
designated class/activity times.

Leisure & Culture Dundee manage a strict policy on the taking and using of video and
photographic images. Participants and members of the public are not permitted to take photographs
or videos at Leisure & Culture Dundee events. Leisure & Culture Dundee obtain consent to enable
officers and members of the press to take video or photographic images for official use only.
These images may used on the Leisure and Culture website, promotional material or social media
for promotional purposes only.

Please tick the box if you DO NOT give permission for your child to be in any videos or
photographs which may be used for promotional purposes
Leisure & Culture Dundee will administer basic emergency first aid in accordance with the relevant
medical authorities. This however, will exclude administration of all medicines, except agreed
use of EpiPen.

Leisure & Culture Dundee asks participants and their carers to adhere to its
Codes of Conduct to ensure the health, safety and enjoyment of all participants. Failure
to do so could result in the participant being excluded from the class/activity. Click here
to see our Codes of Conduct that should be adhered to.

Click here to open and read declaration and click here to open and read Data
Protection Info.

Your details will be retained on a database for use only by Leisure & Culture Dundee.
These details will not be passed to any other agency or third party.

I declare that the information given in this form is correct at time of writing.

I confirm that I have read and acknowledge the codes of conduct, declaration
and data protection info. *
Please tick the box if you DO NOT wish to receive information on other programmes
and activities run by Leisure & Culture Dundee.
HOW DID YOU HEAR ABOUT US?
*