Parental Consent Form – PiPeLine Keighley

Your Details

PiPeLine Productions Academies are alternative education provisions that support young people back into learning using a variety of methods to re-engage and re-motivate young people into achieving. With our highly experienced and dedicated staff, we use these tools to engage young people into the learning package that we provide. It is our aim that all of our learners will achieve nationally recognised GCSE equivalents whilst studying at PiPeLine Productions Academies. Please note; through this programme it may be necessary to leave the site on rare occasions to take part in external educational experiences. If a visit requires an analysis of further risks, we will seek your consent separately.

Young person’s name: *

Has been referred to PiPeLine by:

DOB: *

We believe that your child will have an enjoyable and productive time whilst on their placement with the PiPeLine Productions Academy. If you agree to your child participating in this programme please complete the details below:

Your full name: *

Relationship to the young person: *

Address: *

Postcode: *

Mobile number: *

Emergency Contacts

In the case of an emergency we will always strive to contact you as a priority using the above details. However, please provide us with one other emergency contact below should we not be able to reach you:

Name of second emergency contact: *

Relationship to the child: *

Telephone number: *

Mobile number:

Please provide the following details in order for us to best support your child whilst on our programme: *

Your child suffers from epilepsy, fits, or drowsiness
Suffers from allergies
Taking medication or receiving any medical treatment
Any other health problems we may need to be aware of
No issues

Epilepsy, fits, or drowsiness *

Please provide details of any diagnosis or medication.

Allergies *

Please provide precise details of any allergies and any required medication.

Medication *

Please provide details of any medication.

Any other health problems. *

Please provide details of any other health problems we need to be aware of.

Name of child’s doctor:

Doctor’s telephone number:

Address of doctor’s surgery:

Statement of Consent

I hereby consent to the above named young person taking part in the PiPeLine Productions Academy Programme. I authorise staff to act on my behalf for the duration of the placement. I also agree that staff at PiPeLine Productions Academy are duly authorised on my behalf to seek any emergency medical treatment required on the advice given by a medical professional. I hereby agree to make good any damage caused by my child whilst attending PiPeLine Productions Academy.

Print name: *

Signature: *

Date of signature: *

Media Consent

I hereby consent to the named young person taking part in videos and photographs as part of their evidence criteria under the supervision of staff at the PiPeLine Productions Academy. As well as being used to evidence work, this may also be used in any promotional material/testimonies of success of the PiPeLine Production Academy. Please sign below to register your consent.

Signature:

Date:

Data Protection/GDPR

The PiPeLine Productions Academy will keep any information about the above named person in a secure place which may be a computerised database system or locked in a secure cabinet. Such information, which is subject to the Data Protection Act 1998, will be used as follows:

Held, used or disclosed only for the lawful purposes and by/to those who may legally have access.

Kept safe and secure.

Will be relevant to the placement of the young person.

Will be made available to the young person where relevant and requested.

Occasionally this information may be shared with other relevant agencies involved with the education, training or support of the said young person for the benefit of the young person. However, a young person may request against this and this will be respected unless it is causes any child protection issues. I understand the above information and I give my consent to records and information about me/my child being held securely.

Signature (Student): *

Date: *

Signature (Parent/Carer): *

Date: *