Support Groups for children and young people

Please select the correct age group from below *

Information about young person

First Name *

Last Name *

Sex *

Date of birth *

Address inc postcode *

School or college young person is currently attending *

GP contact details inc postcode *

Parent or guardian information

First name of parent *

Last name of parent *

Parent or guardian address inc postcode *

Phone number *

Email Address *

Please tell us about the child who has died *

Childs name *

Child' date of birth *

Emergency contact information

Emergency contact 1 - name *

Contact number 1 *

Emergency contact 2 - name *

Contact number 2 *

Medical information

Please detail any medical condition the young person wishing to attend has:

Any medication required during the event *

YesNo

If yes please please list medication name and dose required

Time of medication dosage

Will the person attending self administer?

YesNo

Do we need to support the administration of medication?

YesNo

Any allergies

YesNo

Is emergency medication required?

YesNo

If yes please give details

If emergency intervention is required, do you give consent for it to be administrated by our first aiders?

YesNo

Please sign to give consent of emergency medical intervention *

Draw signature|Type signatureClear

Consent to contact you

Throughout the duration of the project, we will send you information reminders and updates of venues and times of sessions we use a system called Cliniko for our bookings, so we do require an emails and mobile number to be able to send you information about each session.

How would you like to be contacted? Please tick all that apply: *

Text PhoneEmail

Use of photographs and videos

The Bodie Hodges Foundation are committed to protecting and respecting your privacy. There are times where capturing images of activities and sessions help us to show other families what happens in the sessions that we run. We also ask from time-to-time adults and young people to be part of films that we make to raise awareness of our services and help others understand the impact of child bereavement on parents and siblings. You being part of this helps to promote our work and ensure that funders have a clear idea of the purpose behind the work that we do.

We will only use images and film that we have obtained consent from you to use, and you can make choices about what sort of images we share on our website, social media, and promotional material. We will always tell you if we would like to use an image even after you have signed a consent form so you will always be informed about where your image may be used.

Please can you complete the questions below and give us consent to use images of your child in the following ways.

I give my consent for images of sessions to be used on social media, website and promotional material *

YesNo

I give consent to take part in filming and for this footage to be used by The Bodie Hodges Foundation on social media, our website and for promotional purposes *

YesNo

As part of the youth project, we often work with other partner agencies who support us with providing activities for the young people they may wish to take photographs during these events. I give consent for partner agencies to take and use images when working alongside The Bodie Hodges Foundation *

YesNo

I confirm I am the legal guardian of the child/young person named above and all information provided is correct and I give consent for them to take part in the project and activities provided.

I confirm *

Draw signature|Type signatureClear

Do you give permission for us to contact you to discuss this referral? *

YesNo

Best contact person and number: *

GDPR Statement

The Bodie Hodges Foundation would like to keep you updated about the services we provide, our work, and how you can support us, including volunteering and fundraising activities.

Your information will be held securely with all reasonable precautions taken to protect it.

We will never swap or sell your data.

We require your consent to process your information.

Your data will be held by the Bodie Hodges Foundation until you request otherwise.

Under Data Protection legislation your rights include withdrawal of consent, objection, erasure, rectification, and access. You can contact the Bodie Hodges Foundation to exercise these rights or to change your contact preferences at any time.

Telephone – 0116 243 6367

Email – office@bodiehodgesfoundation.co.uk

Post – Bodies House, Bodie Hodges Foundation 254 Braunstone Lane Leicestershire LE3 3AS