Summer Passport 2021

Gosport Summer Passport

1. First Name:*
2. Surname:*
Address:*
Postcode:*
Childs date of birth*

Day

Month

Year

Only enter numbers
School*
Is your child entitled to free school meals?*
1. Yes
2. No
Would you like a Summer Passport free bus Pass?*
1. Yes
2. No
Can your child swim 50m unaided?*
1. Yes
2. No
Parents/guardian email address:*
Emergency contact name:*
Emergency contact telephone number:*
Participant Monitoring Information
Disability?*
1. Yes
2. No
If yes, please give details of any medical or behavioral issues and special requirements
Disability - select all that apply
1. Learning
2. Hearing
3. Visual
4. Physical
5. Multiple
6. Mental Health
If there is any other information you think we should know to ensure the participation of your child, please give details:
Photo Consent*
1. I do not give permission for my child to be photographed
2. I do give permission for my child to be photographed
Images may be used by Gosport Borough Council & partner organisations in printed materials including Coastline magazine and leaflets; on websites including Gosport Borough Council and Safer Gosport; and social media including Facebook, Twitter and Instagram
I have read and understood the information provided and give permission for the person named to participate in the Gosport Summer Passport Scheme 2021 activities. I understand that they have a responsibility to behave appropriately and that if they do not adhere to the behaviour code, they will be excluded or further action will be taken. In the event of a medical emergency I give my consent for all necessary treatment. I confirm that I am the parent/person with parental responsibility of the child named.
Name:
Relationship:
The personal data provided is processed by Gosport Borough Council (GBC) for safeguarding purposes. It is retained for one year and is not used for any other purposes. You have the right to withdraw data consent and you can access your data by contacting GBC. Statistics from the data informs planning of future Summer Passport Activities and evaluation. I consent to the information within this form being collected and used for these purposes. I confirm that consent from the young person to provide their data has been given*
1. Yes

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