Please confirm that you (the parent carer) agree to sharing your information with Amaze*

What is your relationship to the young person?*

Your first name*

Your last name*

Your email address*

Your mobile number*

Your gender*

Do you live at the same address as the young person?*

First line of your address*

Second line of your address

Town/City*

Postcode*

Tell us anything we need to know about so we can keep you safe and comfortable taking part in our activities e.g. allergies, online safety issues, safeguarding, bullying, sensory needs, distressed behaviour. You can share this here or you can write that we need to call you or your parent carer so you can tell us more.*

Tell us a bit about you so we have an idea of what you like doing and what you want/need from us e.g. hobbies, interests, how you communicate.

Your first name*

Your last name*

First line of your address*

Second line of your address

Town/city*

Postcode*

Email address*

Mobile number*

Your date of birth*

What is your gender?*

If not listed, how do you describe your gender?

What is the sex you were assigned at birth?*

What pronouns should we use for you?

What pronouns do you use?

What is your ethnicity?*

How do you describe your ethnicity?

What is your sexuality?

How do you describe your sexuality?

Please tell us your disabilities, long term health conditions or neurodivergence?*

Which project do you want to access?*

What is the name of your GP surgery?*

Their full name*

Their phone number*

What is their relationship to you?*

Are you happy for us to share some anonymised information about you with the NHS?*

Are you happy for Amaze to use photos of you?

Are you happy for Amaze to use videos of you?

Are you happy for the photographer to use photos of you in their portfolio?