What's On

December 2025

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Nurse Appointment
15 min
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Summer 2026

Summer Holiday Programme Permission Form January 2026

Whanake Youth (Youth Health and Wellbeing Charitable Trust)

Programme Dates:

Week 1: January 13th, 14th, and 15th, 9:30am - 4:30pm

Week 2: January 20th, 21st, and 22nd, 9:30am - 4:30pm

Location:

Whanake Youth Hall, 548 Main Road Stoke, behind the old Stoke Memorial Hall

APPLY HERE

Participant First name:*

Participant Last name

Date of Birth:

Day

Month

Year

Contact Email:

Best Contact Phone #:*

Address:

Parent/Caregiver Name:

Parent/Caregiver Phone #:

EMERGENCY CONTACTS:

(Please list two contacts other than the parent/caregiver above.)

Name:

Relationship:

Phone #:

MEDICAL INFORMATION:

Doctor/Medical Centre: (Include phone number)

If you ticked any of the above, please provide details, including triggers, symptoms, and treatment plans:

Medications:

Does your young person require medication during the programme?

Yes

If yes, please provide administration instructions:

Do you give permission for staff to administer approved first aid treatment if required?

Yes

ACTIVITY PERMISSION

How did you hear about us?

Friends

Social Media

School

Other

The programme may include (but is not limited to): local trips, outdoor games, sports, off-site excursions, arts and crafts, cooking, water-based activities, technology sessions, and supervised free time.

Please tick to give permission to the following:

Permission for all scheduled programme activities.

Participation in off-site trips (walking or supervised transport)

Participation in water-based activities (e.g., pools, beaches, water parks).

Permission for staff to transport my child in programme-approved vehicles.

If there are any activities you do not consent to, please list them:

Tell us about your young person, are there specific interests or ways to best support them to have fun on the programme?:

BEHAVIOUR AND SUPERVISION AGREEMENT

The holiday programme follows behaviour expectations based on respect, safety, and responsibility.

Parents/caregivers acknowledge that:

Staff will provide appropriate supervision for 12 - 15 year olds, but encourage age-appropriate independence.
Unsafe or severely disruptive behaviour may result in parents/caregivers being contacted, or removal of the young person from attending the programme.
Young people must follow staff instructions and treat others respectfully.

Parent/Caregiver Signature:

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Young person signature or initials:

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PHOTO/VIDEO PERMISSION:

Photos or videos may be taken for programme records, newsletters, or promotional materials.

Multi choice

Yes, I give permission for my young person's image to be used.

No, I do not give permission.

SIGN-IN/SIGN-OUT

12 - 15-year-olds may be allowed to sign themselves in/out only if permitted by a parent/caregiver.

Multi choice

I give permission for my young person to sign themselves IN.

I give permission for my young person to sign themselves OUT.

My young person MUST be signed in/out by an authorised adult.

Details of authorised adult/s for pick up:

CONSENT AND DECLARATION

I, the parent/caregiver of the above-named participant:

Declare that the information provided is true and complete.
Give permission for my child to attend and participate in the Whanake Youth Holiday Programme.
Understand that the programme follows Whanake Youth health, safety, and behaviour standards.
Agree to notify staff of any changes to medical or contact details.
Agree to notify staff if the participant can no longer attend any of the days they are registered to attend.
Acknowledge that while staff take all reasonable precautions, activities involve inherent risks.

Parent/Caregiver Signature:

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Date

Day

Month

Year

What's On

December 2025

Nurse Appointment

Summer 2026

Summer Holiday Programme Permission Form January 2026

APPLY HERE

EMERGENCY CONTACTS:

MEDICAL INFORMATION:

ACTIVITY PERMISSION

BEHAVIOUR AND SUPERVISION AGREEMENT

PHOTO/VIDEO PERMISSION:

SIGN-IN/SIGN-OUT

CONSENT AND DECLARATION