1st

Rainford 10th St Helens

Scout Group
Young Person Information

Surname Ethnicity
Forename Religion/Faith
D.O.B Gender
Address/No
Street Section
Town Beavers
County Cubs
Postcode Scouts

GP/ Surgery Name

Surgery Address Surgery Number

NHS Number

Postcode

So that we can consider any support we, or you, may need to put in place to ensure this child can get the most
out of scouting please state here any additional / special needs / dietary. Please circle as appropriate from the
following, providing additional details as required and giving thought to the types of activities we do:

Developmental (e.g. ADHD/ADD, Autistic Spectrum Disorder, Dyslexia, Dyspraxia)

Injury (e.g. Body, Brain)

Physical (e.g. Spina Bifida, Downs Syndrome, Cerebral Palsy)

Medical (e.g. Allergies, Arthritis, Asthma, Diabetes, Epilepsy, ME/Chronic Fatigue)

Mental Health (e.g. Bipolar, Depression, Eating Disorder, self-harm)

Progressive (e.g. Muscular Dystrophy)

Sensory (e.g. Hearing, Vision)

Other (e.g. bed wetting, sleep walking, dietary)

State here full details of any medication taken / ongoing medical treatment being received:

Any other information that may affect your childs ability to take part in an activity or that could
affect other members:

YP MEM FORM 2017

 1st Rainford 10th St Helens
Scout Group
Parent/Carer Information

Parent/Carer 1 Parent/Carer 2
Surname Surname
Forname Forname
Relationship Relationship
Address Address
Number Number
Street Street
Town Town
County County
Postcode Postcode
Home Tel Home Tel
Mobile Tel Mobile Tel
Email Email

Emergency Contact
Surname
Forname
Relationship
Address
Number
Street
Town
County
Postcode
Home Tel
Mobile Tel
Email

By signing and dating below I confirm:

The information on this form is true, accurate and complete

I have declared in detail all special needs and all other relevant information

I understand that if my child has been issued with an EpiPen / Anapen or an inhaler it is my responsibility
to ensure they take them with them, even to weekly meetings, and to show the section leadership team
how to use that specific type of EpiPen/ Anapen

Signed .. Date..

YP MEM FORM 2017