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Irlen Consent & Confirmation Form

Irlen Consent & Confirmation

"*" indicates required fields

Step 1 of 2 - Consent form

Child / Young Person's details

Name*
DD slash MM slash YYYY
Gender*
Preferred Pronouns*

Parent/Carer details

Preferred Pronouns*
Name*
Address*

Alternative contact details

In case of an emergency and we're unable to get hold of you.
Preferred Pronouns
Name
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.
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.
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.
Clear Signature