Student's Name *

First Name

Last Name

Student's DOB *

MM

DD

YYYY

Parent / Carer's Name *

First Name

Last Name

Name *

First Name

Last Name

Permission for us to share medical/disability information with authorised staff if needed *

I give permission for Limepalm Ltd to share medical/disability information with authorised staff if needed (e.g. your child / young person's teacher).

YES

NO

Permission for emergency treatment *

I give permission for Limepalm Ltd staff to obtain any medical treatment or assistance that may be necessary in the case of an emergency for my child / young person (as named on this form).

YES

NO

Permission to administer prescribed medication *

I give permission for a First Aider to administer medication prescribed by a doctor. A written record will be kept. An additional form will need to be completed.

YES

NO

Permission to use plasters *

I give permission for the first aid trained staff of Limepalm Ltd to apply plaster(s) to my child / young person if necessary. By agreeing to this you are confirming that your child is NOT allergic to plasters

YES

NO

Permission to take photographs *

I give Limepalm Ltd permission to take photos/video during classes, workshops, events and performances for the purposes of marketing, publicity and/or archiving. These will never be shared with any identifying information (age, location etc). There may be times where we will share first names, but only with the explicit consent of the parents and students involved.

YES

NO

Some attendees at events may film/take photos for their own personal use (e.g. parents of other participants). Do you consent to this? *

Please understand in the interests of Data Protection, by selecting 'NO' we will not be able to allow any parent/guardian to record a show in which your child / young person appears.

YES

NO

Permission to send infrequent information via email regarding further Limepalm Ltd courses and events *

I give permission for Limepalm Ltd to send me infrequent information via email regarding further Limepalm Ltd courses and events. This data will be stored in line with our Data Protection Policy which can be found on our website.

YES

NO

I, the undersigned, am legally responsible for the child / young person detailed on this form and confirm the information I have supplied is correct to the best of my knowledge *

Please tick to confirm

YES

Digital Signature (parent/guardian) *

First Name

Last Name