MPA Medical & Social Media Consent Form

THIS FORM IS TO BE COMPLETED BY THE LEGAL CARER OF THE CHILD BEING ENROLLED TO MARK PROCTOR ACADEMY. LEGAL CARERS ARE RESPONSIBLE FOR INFORMING MARK PROCTOR ACADEMY OF ANY CHANGES AS THEY OCCUR.

* FIELDS ARE REQUIRED INFORMATION

MARK PROCTOR ACADEMY RESPECTS YOUR PRIVACY

Any personal information you provide to us including and similar to your name, address, telephone number and e-mail address will not be released, sold, or rented to any entities or individuals outside of Mark Proctor Academy.

Parent Name

First Name

Last Name

Child Name

First Name

Last Name

Childs current school (i.e Year 3)

Contact number

Address

Child Health Information

Does your child currently have any health needs? e.g. diabetes, asthma, epilepsy, allergies. If so, please give full details below including medication taken.

Social Media Consent *

At times, Mark Proctor Academy may wish to take photos or videos of group sessions or individuals involved in Mark Proctor Academy sessions. These then may be used and shared via social media.

I am happy for my child to be part of MPA's social media

I do not wish for my child to be part of MPA's social media

Additional Comments

I confirm the information above is correct and I will inform MPA of any changes as they occur

Yes