JIAS Consent & Confirmation Form

Step 1 of 3 - Consent form

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Child / Young Person's details

Name*

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 individual*

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 form

Consent to take part*

I am happy for me/ my child/ my young person to take part in this assessment. I understand that, while bibic will take all reasonable care of me/ my child/ my young person unless they are negligent, they cannot be held responsible for any loss, damage or injury suffered by me/ my child/ my young person.

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 me/ my child/ my young person’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

I have read and understood bibic's terms and conditions

Yes

Please ensure you have read and understood the JIAS audiogram/appointment cancelation and reschedule terms.

Read bibic’s Terms and Conditions

Signature*

Signature date

Confirmation Form

Attending*

I confirm that we will be attending our assessment.

During assessment student placements may be present.

Use of headphones*

During the JIAS programme, the individual will not be able to listen to anything else through headphones for the duration of the programme. If the individual listens to anything through headphones this will impact the effectiveness of the music therapy. Please tick below to confirm understanding.

I understand

Equipment*

Please ensure you have purchased the correct headphone as well as the Sonorias app before starting you JIAS programme.

I understand

Please ensure you reference your invoice number when making internet banking transfers, failing to do so may delay the process.

Please note once you have started the JIAS programme it is non-refundable.

How are you paying?*

Option 1 - I have paid in full

Option 2 - I am paying in two parts (full payment is required one month prior to the assessment date).

Option 3 - I will pay in full

Please select the relevant payment method 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 cheque for the full payment on the date specified below

I have discussed with JIAS lead my payment option

Date payment made:*

DD slash MM slash YYYY

Please put in the date the payment was made.

Comments

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

JIAS Consent & Confirmation Form