Health Form (ages 16+)

To be completed by every Young Leader, Youth Leader and Team Member attending Impact

Health Form (ages 16+)

To be completed by Young Leaders, Youth Leaders, and Team Members

Full Name, Address, Email, Phone Number

Date of Birth

GP Name and Surgery Phone Number

Do you suffer from any allergies?

Are you on any medication or any other treatment?

Please describe any medical conditions / history that we ought to be aware of:

Are you on a special diet? (e.g. gluten free, vegetarian) Please give details below

Please give the name and contact details (address and phone number) of next of kin who can be contacted in an emergency (if you are under 18 please provide details of a parent or guardian):

Please check all boxes that apply

Do you use an inhaler? (if so please indicate which type under 'medications')

Have you had a tetanus injection in the last 10 years?

In an emergency are you happy to receive hospital treatment, including an anaesthetic?

Declarations

I confirm that the above information is correct and up to date

I confirm that I am physically fit to participate in the Impact Activities Weekend

I am over 18, or if I am under 18 and I confirm that a parent/guardian has checked this box for me

Thanks for submitting!

Adult Health form

If you require a paper copy of this form, please download it with the button below

Health Form

Data Protection Statement

Under Data Protection legislation the Charity Trustees of the North Western Baptist Association are the Data Controller and can be contacted by ringing 01942 221595or emailing dataprotection@nwba.org.uk

We are collecting this information to enable the NWBA to run the Impact Activities Weekend and {Disciple} Programme safely and ensure we can contact you (or your next of kin) in case of an emergency.

Data Protection legislation allows us to process this information as we regard it as being in the Association’s legitimate interest. If you are unable to supply the information requested then we will be unable to accept your application to attend the weekend.

The information you supply will be held electronically on the Association Sharepoint and Impact email inbox which is password protected and accessed only by the NWBA Team. Information will also be stored in paper form in a folder which will be kept in a securely locked cupboard in an Association office. This information may be shared with the Impact Team as appropriate for the sole purpose of running this event.

We will destroy data in accordance with NWBA’s Data Retention Policy. Safeguarding information such as records of DBS clearance will be retained for 75 years according to our Data Retention Policy. We will NOT pass on this information to anyone else.

If you are concerned about the way your information is being handled please speak to our Data Protection Trustee. If you are still unhappy you have the right to complain to the Information Commissioners Office.