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

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

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

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

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

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

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.

During assessment student placements may be present.

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 fee consent*

I agree to pay any cancellation fees applicable.*

Cancellation list*

Add me to cancellation list

Don't add me to the cancellation list

Please tick if you would like to be added to our cancellation list. (You must pay quarter of the amount beforehand; this payment can be made over the phone, via bank transfer or you can set up an early payment plan).

Attending*

I confirm that we will be attending our assessment.

Payment

I am eligible for military discount:

Yes

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 before and half via payment plan

* Please note: half of the cost is required to be paid a month before the assessment day.

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

This field is for validation purposes and should be left unchanged.