Mentoring Consent Form & Risk Assessment

1About the young person

2Emergency Contacts

3Medical Information

A referral form for your young person to be matched with a Mentor has been received by The Hive. To ensure that we have all the most relevant up to date information relating to your young person, please complete this form which notifies the Mentoring Co-ordinator. Should we be able to successfully match your young person, please ensure that you keep the Mentoring Co-ordinator updated with any change of circumstances the Mentor will need to be made aware of, for example: a change of address or medical needs.

Email of Parent/Carer *

Confirm Email

Name of young person *

First

Last

Do you have full parental responsibility for this young person? *

Is the young persons other parent/carer aware that they are entering our mentoring programme? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of birth *

Age *

Gender *

Male
Female
Other
Prefer not to say

If other, please describe gender below *

Emergency contacts

Please give details of two people who can be contacted in an emergency, one of which must be a parent, carer or guardian:

Emergency Contact 1: Name *

First

Last

Relationship to young person *

Emergency Contact 1: Contact number *

Emergency Contact 1: Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Emergency Contact 2: Name *

First

Last

Relationship to young person *

Emergency Contact 2: Contact number *

Emergency Contact 2: Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Is there any information you would like to Mentoring Coordinator to know that may help the mentoring relationship? *

Does your young person have any medical conditions which may affect your ability to participate in activities and stays (i.e existing injury, pregnancy or illness) *

If YES, please give full details: *

Does your young person suffer from any of the following conditions? (please tick all that apply) *

Asthma
Bronchitis
Chest Trouble
Diabetes
Epilepsy
Fainting
Heart Problems
Migraine and Headaches
High Blood Pressure
Tuberculosis
Low Blood Pressure
Disease of the blood
Depression
Other - Anxiety / ADHD / Autism

Other includes: any visual or hearing impairment, broken bones, muscle injuries. If answering YES or OTHER please give full details below; *

Do your young person have a disability? *

If yes please give details *

Does your young person suffer from any other condition requiring on-going medical treatment, including medication? *

If yes please give details *

Do your young person have any allergies to medication, insect bites, food or plasters? *

If yes please give details *

Has your doctor advised your young person against taking any physical exercise? *

If yes please give details *

Does your young person have any special dietary requirements? *

If yes please give details *

Does your young person have any phobias? (strong fear or dislike of something?) *

If yes please give details *

Has a risk assessment been undertaken on the young person that we need to be aware of? *

If yes - please provide details *

Does the young person have a statement of educational needs? *

If Yes – who is the best person to contact about meeting these needs? *

Is the young person a risk to themselves? *

If yes - please provide details; *

Is the young person a risk to others? *

If yes - please provide details; *

Is there anybody the young person is not allowed to have contact with, without consultation with yourself? *

If Yes – please provide more information; *

Is the young person aware of this? *

Do you have any further information you think the Mentoring Co-ordinator should be made aware of to keep the young person and Mentor safe?

If Yes – please provide more information *

Things to Consider: Mental Health concerns, Problems at home, Problems at school, Friendship concerns, History of offending, History of alcohol & substance misuse, Risky behaviours, Behavioural plan, Ongoing medication.

Media Consent: I give permission for photographs and videos of my young person to be used for personal use

I give permission for photographs and videos of my young person to be used in publicity material for The Hive Wirral Youth Zone, including social media

Medical Declaration: I agree to my young person receiving emergency medical treatment, including anaesthetic and blood transfusions, as considered necessary by a qualified medic

I agree to inform the Mentoring Coordinator as soon as possible of any change in the medical circumstances OR details for risk assessment, between the date on which I completed this form and the end of the mentoring programme. This will result in a new medical form being completed.

Declaration: I agree for my young person to be driven by the mentor/Mentoring Coordinator during these sessions

I consent for the mentor to receive my young person’s date of birth and address for emergency purposes.

I consent for my young person to sign the communication agreement with their mentee and exchange mobile phone numbers/email address to make arrangements for meetings.

Yes
No
Not applicable - under age 13

In signing below, you give consent for your child to join the Hive mentoring programme, including meeting the mentor at the Hive and attending offsite activities throughout their time on programme. Your child will sign a boundary agreement; if you would like a copy of this then please contact the Mentoring Coordinator at sandra.platt@thehiveyouthzone.org.

You give consent for the young person above to join the Hive mentoring programme, including meeting the Mentor at the Hive and attending offsite activities. (You will be notified of proposed activities in advance for young people under 13 by the Mentoring Co-ordinator or the mentoring who you have your communication agreement with). *

I Agree
I Disagree

When I arrive at reception with my young person, I will wait to make sure that the mentor is there before leaving *

I Agree
I Disagree

Parent / Guardian signature *

First

Last

Young Person's Name *

First

Last

Date

This form was completed by (please enter name and contact email below)

Emergency contacts

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