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Common Room North Ltd. is a company registered in England and Wales.

Registered No. 12240515.

VAT Registration No. 334656393.

Get in touch

555-555-5555

mymail@mailservice.com

Parent / carer consent form

Your child has asked to take part in [name of activity]. This is to help us [Include the purpose of the activity e.g. gain the views and experiences of children who have stayed in inpatient settings in order for NHSE to consider these when looking to improve their services. E.g., to create some imagery for Common Room to use on its website and social media channels, in marketing materials and in reports and presentations.]

Focus groups/discussions

Throughout the session we will be taking notes about what your child says to us, noting down quotes in their own words as well as noting down themes from conversations. We plan to use these notes to [include details of how the notes may be used e.g. create a report or presentation]. These will be shared with [include specific details of agencies with whom the materials will be shared with e.g. NHS England]. [State also if any of the information or reports are likely to be published online and if so which websites]. We might also want to share some of their quotes on social media but would not do any of this in a way that could identify them.

Audio / photography / video

We will be using audio recordings featuring your child’s voice / taking photographs of your child / using video recordings of your child as part of [insert name of activity]. These recordings [images] will be published and shared with [insert details of commissioners or others with whom the audio will be shared] and on the following online public platform/s [insert details of platforms where it will be shared e.g., MindMate or common room website] where they will be accessible to members of the public and shareable.

Anonoymity

We will keep your child’s personal information anonymous. This means that we will not share your child’s name, date of birth, or contact details with anyone outside of Common Room. We may share details such as age and general location [give relevant example e.g. West Yorkshire, Leeds, LS7] [Also include any other identifying details you plan to share e.g. school, initials etc.] but not details that would make individuals identifiable. We will also share demographic details such as ethnicity, gender etc but these details will be taken from the separate anonymous Diversity monitoring form so would not be linked to your child’s name at all.

Safeguarding

Common Room takes safeguarding it’s participants seriously and has a safeguarding policy which all staff work to. As part of this policy, we work to the following confidentiality statement.

Common Room Confidentiality Statement
Common Room offers confidentiality to children, young people and adults we engage with through our work, including staff members. This means we will not normally share information about you to anyone outside the organisation without your agreement. We will keep information about you secure only until it is no longer needed and share this on a need-to-know basis.
There may however be times when we need to share information about you with external partners or organisations when we are concerned that you or someone else are in danger or at risk of significant harm. Wherever possible we will try to discuss this with you and gain your consent before giving out any information. However, if we are unable to do this and feel that telling you would increase the risk, we may choose to do so without your consent.
If you are unsure or would like to know more about the above, please ask one of the workers or email liz.neill@commonroom.uk.com

Storage of personal data

These [notes, images, recordings], they will be securely stored by Common Room for a period of up to 5 years when they will be deleted (unless required for safeguarding investigations). You have a right to remove your consent at any time in this period. If you do remove your consent however, it may not be possible to delete those that have already been shared or published.

Final versions of materials developed from this activity will be kept on file to be used internally for reference only in the development of new resources.

Images of participants where they are not identifiable (e.g., images of feet or hands) may be used for an undefined period and will not be removed after 5 years unless explicitly requested by the subject or their parent or guardian (if under 16 years old).

What next?

If you have any questions about any of the above please contact liz.neill@commonroom.uk.com.

We need your consent to say that you agree for your child to take part in this activity as outlined above.

Please fill in your details below and tick the boxes below to say you give your consent for your child to take part.

Your name

Email address or mobile phone number

Name of child

Date of birth of child

Tick the boxes to give your consent

1. I am happy for my child to take part in [activity name as above]

2.a. I agree that what my child says may be used in written resources as described above

2.b. I am happy for Common Room to take digital images / recordings of my child for the purposes outlined above.

3. I agree that any materials produced from this activity may be used as stated above for a period of up to five years.

4. I understand that I can withdraw my permission at any time. This includes before, during or after the activity has taken place. I can do this by emailing Liz Neill.

5. I also understand that once materials have been published or entered the online public domain it is impossible to fully retrieve them.

6.a. I understand that Common Room will not use my child's name or identify them in any way without my specific consent.

6.b. I understand that Common Room will not use my child's name in association with the images/recordings without my specific consent.

Common Room North Ltd. is a company registered in England and Wales. Registered No. 12240515.