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Consent and confirmation
Home
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Consent and confirmation
Step
1
of
2
- Consent form
50%
Child / Young Person's details
Name
*
First
Last
Date of Birth:
*
DD slash MM slash YYYY
Age
*
Gender
*
Male
Female
Non-binary
Other
Parent/Carer details
Name
*
First
Last
Relationship to the young person
*
Address
*
Street Address
Address Line 2
City
County
Postcode
Daytime phone: Mobile phone
*
Email Address
Alternative contact details
In case of an emergency and we're unable to get hold of you.
Name
First
Last
Relationship to young person
Their daytime phone
Their mobile phone
Consent to take part
*
I am happy for my child to take part in this assessment. I understand that, while bibic will take all reasonable care of my child, unless they are negligent, they cannot be held responsible for any loss, damage or injury suffered by my child.
Yes
No
Consent to authorise medical treatment in an emergency
*
I give consent for bibic to administer basic first aid, and/or authorise medical treatment (as advised by medical staff) should it be deemed in the interest of my child’s health and safety to do so.
Yes
No
Consent to take and use photographs/videos of young person
*
Featuring family stories, photos, videos and quotes in our marketing and communications can help bibic raise more money or help other families understand how bibic can help their child.
I am happy for photographs and/or video of my child to be taken whilst taking part in the sessions and used to publicise the work of bibic and to our funders, and other fundraising purposes. To protect privacy we will not use names unless the child is part of our Sponsor a bibic child programme.
Yes - Both images and video
Yes - Images only
Yes - Videos only
No
Consent to store and process data
*
I consent to our data being gathered, stored and processed (in line with our privacy policy) so that bibic can provide support to my child. I understand that these details will be kept for up to 7 years. All data will be securely stored and not shared with any third parties.
Yes
No
Consent to be contacted by our Fundraising and Marketing department
*
bibic need to raise £1,485 towards the cost of every full assessment, therapeutic plan and support for families. We would like to keep in touch with you about fundraising and marketing. I consent to bibic contacting me about fundraising events, activities, and marketing.
Yes
No
I would like to be contacted by:
We will keep your information secure. You can change how we contact you at any time by:
• Email info@bibic.org.uk
• Calling 01458 253344
• Writing to bibic, Old Kelways, Somerton Road, Langport, TA10 9SJ
Post
Email
Phone
Signature
*
Signature date
Confirmation Form
Please read all the information and ensure you understand it fully, failure to do so may result in a fee being applied or the assessment being cancelled.
Cancellation fees
2 weeks cancellation prior to assessment (£100)
1 week cancellation prior to assessment (£200)
Not turning up on the day (50% of assessment cost- £300)
Cancellation list
*
Please tick if you would like to be added to our cancellation list. (You must pay half of the assessment amount beforehand; this payment can be made over the phone, via bank transfer or you can set up an early payment plan).
Add me to cancellation list
Don't add me to the cancellation list
Attending
*
I confirm that we will be attending our assessment.
Payment
Please use your invoice number in the payment reference when paying via bank transfer.
*
Option 1 - Paying the full amount
Option 2 - Paying half before the assessment and half after
Option 3 - Paying full via payment plan
Option 4 - Paying half full and half via payment plan
Please note: If you are not paying in full, half of the cost of your assessment MUST be paid a month prior to the assessment date.
Payment Plan
By selecting to pay by Payment Plan a GoCardless link will be sent to you via email on receipt of this form.
Monthly amount
Number of months
Full amount
Start date
DD slash MM slash YYYY
Name
This field is for validation purposes and should be left unchanged.
Please complete the required information in full within two weeks – if you need any help, please contact 01458 253344
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