MOBBERLEY PARISH COUNCIL

Your son/daughter has been invited to participate in the following event

Queen’s Diamond Jubilee Disco – ages 10 - 15 years of age
Sunday 3rd June 2012 Mobberley Victory Hall 7pm – 9pm
Please complete and return this form with any ticket order you may have.

• I confirm that I would like my son/daughter to attend this event.

• I enclose payment of £4 (cheques to be made payable to Mobberley

Parish Council, please)

• I will ensure suitable transport arrangements are in place for my child to

attend this event.

Childs Name

Event Children’s Disco – Queen’s Diamond Jubilee

Telephone contact
during the event,
relationship to child,
your home address

Medical conditions that

the organisers should
know about e.g.
Diabetes, Heart
problems, Migraine,
Allergies etc

Current medication,
pain or flu relief that
can be given

Medical Practice and

Doctor

Special dietary
requirements

I agree to my child being given any medical, surgical or dental

treatment, including general anaesthetic and blood transfusion, as Yes/No
considered necessary by the medical authorities.

To your knowledge your child is in good health and physically

able to participate in the activity above Yes/No
(If your child has any pre existing medical conditions, please provide a letter from yourself or the
appropriate medical practitioner confirm that the student is fit to travel and take part in this particular trip)
 CODE OF CONDUCT

All children attending the Children’s Disco are required to read and sign the following
Code of Conduct.

Each child must:

• Co-operate fully with the organisers and accompanying adults at all times.

• Not leave the disco without permission.

• Behave at all times in a manner which reflects credit on themselves.

• Be considerate to others at all times and avoid inconsiderate behaviour

• Fulfil all request and requirements made by organisers and accompanying adults.

• Not purchase or consume alcohol, tobacco products or purchase dangerous articles

such as fireworks and knives.

• If in doubt consult an organiser or accompanying adult.

DECLARATION

• I have read all the details regarding the proposed disco.

• I give consent to my child taking part in the disco, declare my child to be in good
health.

• I have noted where and when my child is to be collected and I am responsible for by
child getting home safely from this event.

• I have completed the required medical form and will return it with this consent form.

• My child and I have read the Code of Conduct and understand that the organisers
will act upon it exercising the same duty of care as would a reasonable parent.

• If my child has to be withdrawn from the disco, it is my responsibility to provide

transport home.

• As part of the event, photographs or video footage may be taken for the use in the
Parish newsletter or local press. Can we use the young person’s photograph in this
way? YES NO

Signature of Parent/Carer………………………………….. Date…………………….

Signature of Child……………………………………………..

Please return this completed form when ordering tickets.