Youth Members Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Youth's Mobile Number (If he/she has one)

(###)

###

####

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Mobile Number *

(###)

###

####

Home/Alternative Contact Number *

(###)

###

####

I acknowledge that this club is based on the following activities, team building, games and socialising, youth support. and most importantly, Fun. Supervised by Youth Leaders who have been trained, certified and Gardaí Vetted. I also understand that this club is for the entire community. We have Religious and non Religious members, and Religion is not enforced, We have discussion groups from time to time based on topics the youth would like to discuss, such as depression, suicide, mental health where we may ask God for guidance and support. However attendance to Religious content is not compulsory. *

I Acknowledge

With the submission of this form, I give permission for my son/daughter to take part in the normal weekly activities. I understand that the group leader and other workers, while taking all reasonable care in looking after my son/daughter, cannot necessarily be held responsible for any loss, damage or injury suffered by my son/daughter during, or as a result of, the group’s activities or if your son/daughter leaves the premises within club time, without permission of a youth leader or parent. *

Agreed.

In an emergency, if I cannot be contacted despite all reasonable attempts to do so, I give permission for my son/daughter to undergo emergency medical/dental treatment including the use of anaesthetics as considered necessary and administered by suitably qualified medical practitioners. *

Agreed.

The Safety of your children is always our main concern. Can you Please indicate if you are happy for you son/daughter to walk home at any point of the evening unaccompanied? *

Yes.

No.

I hereby consent to the taking and use of images or video of my son/daughter during Hype events, to be used on Social Media Platforms such as, Facebook, Instagram, Twitter and the Hope Cafe Website. This material may used in Youth Club Promotions and/or marketing. The content will be screened and deemed proper by our Head Leaders and marketing team. Please note your consent can be withdrawn at any time, by contacting us.

I fully consent to the above

I do not consent

By submitting this form I apply for my son/daughter to become a member of the HYPE Youth Club Shannon and acknowledge that they will become an official member on submission of this form. We will contact you via email, and phone to oficially welcome new members. *

I hereby confirm membership

Parent/Guardian Signature *

First Name

Last Name

Date of Submission *

MM

DD

YYYY