Wellbeing Family Support Consent

family Support Parents & Carers Consent Form

If you have any questions, concerns or need support completing online forms and bookings please call the Care Team on 01702 552 200.

Young person's name*
First Last
Young person's email address
Date of birth*
DD slash MM slash YYYY
Phone*
Address*
Street Address Address Line 2 City Postal code
If your child has any allergies or medical needs please ensure that you advise us before sessions commence.
Parent/guardian details:
Name*
First Last
Email
Address*
Street Address Address Line 2 City Postal code
Phone
Emergency Contact Number*
Consent
I have read and understood the information given to me regarding the services Havens Hospices child support team provides. I understand that if I have further enquiries, I can discuss them with the staff. I understand that while the child/young person named above is working with the Havens Hospice support worker, he/she will be subject to the service’s code and conduct of behaviour and will be required to conform with the instructions and guidance of the service. If you agree that the named child/young person above should participate in Havens Hospices support services, please sign below. Thank you.
Parent/carer full name - this will be used as your electronic signature*
Consent*
I agree that my full name in the field above will be used as my electronic signature
Date*
DD slash MM slash YYYY