HYAG Consent Form

All sections need to be completed and signed by a parent/guardian of the participant (young person) unless the participant is over the age of 16.

This form must be completed prior to the young person’s attendance at a Humber Youth Action Group (HYAG) virtual or face to face event and covers all activities undertaken as part of the HYAG membership. During the Humber Youth Action Group sessions you will have the opportunity to provide information on your thoughts, ideas, insights, feedback and experiences. This information will be used to help inform Humber Teaching NHS Foundation Trust’s understanding of the delivery of care, to enable us to make decisions about improvements to the care we deliver within our organisation. On some occasions our partner and community organisations may attend the Humber Youth Action Group. Consequently, the aforementioned information shared during Humber Youth Action Group sessions will also help to inform the services/care delivered within partnering and community organisations. There may be occasions where the services use direct quotes in relation to information you have shared, however when this happens it will not be attributable to you outside of the sessions. All engagement/coproduction/participation activities undertaken by members of the Humber Youth Action Group are optional.

The information supplied in the consent form will only be shared with people facilitating the HYAG meetings/workshops in order that they can keep your child safe. The information will not be shared with others.

The Humber Teaching NHS Foundation Trust works towards a policy of respect, equal opportunities and expected level of behaviour. Participants will be expected to follow this policy, and those choosing not to will be asked to leave.

Communication and Promotion

To promote the work of the HYAG we would like to showcase the work of the group through photographs, videos, social media posts and audio recordings. Participants may also be asked to join a WhatsApp group if they choose to take on additional responsibilities. No personal details should be shared within the WhatsApp group, however please be aware the participants phone number will be visible to other participants within the group. If you are in agreement with the above, please tick this box below.

Agreement Checkbox

Participant (Young Person's) Detail

Full Name*

Preferred name*

Address line 1*

Address line 2

Town*

Region

Postcode

Country

Young person's educational setting

Name of educational setting’*

Identifying gender*

Preferred Pronoun*

Ethnicity*

Date of Birth*

Young person's email*

Young person’s mobile number*

Home telephone number*

Mobile telephone number*

Participant’s Medical Information

Are there medical issues/conditions that the HYAG facilitators needs to be aware of? For example, food/medical allergies, medications, asthma, epilepsy, etc.

If the participant is taken ill during a meeting/workshop the HYAG facilitator will ensure that they inform the participants emergency contact and ensure that appropriate medical treatment is sought in line with duty of care.

Enter the participant's medical information here

Parent/Guardian Details (Required if the young person is under the age of 16)

Parental/guardian email address for correspondence

Participant signature

Date signed

Emergency Contacts (optional for young people aged 17 and above)

First emergency contact

Name

Address line 1

Address line 2

Town

Region

Postcode

Country

Telephone

Second emergency contact

Name

Address line 1

Address line 2

Town

Region

Postcode

Country

Telephone

HYAG Consent Form

Communication and Promotion

Participant (Young Person's) Detail

Participant’s Medical Information

Parent/Guardian Details (Required if the young person is under the age of 16)

Emergency Contacts (optional for young people aged 17 and above)

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Care Quality Commission