Irlen Consent & Confirmation Form

Step 1 of 2 - Consent form

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

Child / Young Person's details

Name*

Title First Last

Date of Birth:*

DD slash MM slash YYYY

Age*

Gender*

Male

Female

Non-binary

Other

Preferred Pronouns*

He/his

She/her

They/them

Parent/Carer details

Title*

Preferred Pronouns*

He/his

She/her

They/them

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.

Title

Preferred Pronouns

He/his

She/her

They/them

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 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

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 and admin fees

There is a 48 hour cancellation period. If cancelled before this, we are able to rearrange your assessment. If you cancel within 24 hours we will keep 50% of the fee paid.

Cancellation fee consent*

I agree to pay any cancellation fees applicable.*

Attending*

I confirm that we will be attending our assessment. (During assessment student placements may be present.)

Payment

We require full payment before your assessment date.

How are you paying?*

Option 1 - I have paid in full

Option 2 - I will pay in full

Option 3 - I will pay in two halves

Please select the relevant option and fill in the below:*

I have paid in full by card over the phone on the date specified below

I have paid in full via internet banking on the date specified below

I have sent a by cheque for the full payment on the date specified below

Date payment made

DD slash MM slash YYYY

Please enter the date your payment was made.

Please select the relevant option and fill in the below:*

I will pay in full by card over the phone on the date specified below

I will pay in full via internet banking on the date specified below

I will send a cheque for the full payment on the date specified below

Date payment will be made

DD slash MM slash YYYY

Please enter the date you will make the payment.

Please select the relevant option and fill in the below:*

I have paid the below amount by card over the phone and will pay the remaining balance

I have paid the below amount via internet banking and will pay the remaining balance

I have sent a cheque for the below amount and will pay the remaining balance

Date of first payment.

MM slash DD slash YYYY

Date of second payment.

MM slash DD slash YYYY