Holiday Club Registration

Christmas Holiday Club 2011
Registration Form

1. Details of child

Name of child *

First

Last

Age *

Date of birth *

Address *

2. Telephone numbers for emergency use

Name of parent/carer *

Home telephone number *

Mobile number *

Name of other responsible person *

Home telephone number *

Mobile number *

3. Other information

Please give details of any of the named child’s medical conditions (eg. allergies, asthma, epilepsy, diabetes, dietary needs) or disability that may affect this activity. *

I give my consent for any medical treatment that may be necessary in the event of an emergency. *

Yes No

I give permission for details from this form to be entered onto the church database. *

Yes No

PLEASE NOTE:

A Child Collection Slip will be given to you when you leave your child with us. For your child’s protection it must be produced when you or someone else comes to collect them. We cannot allow them to leave with anyone else unless you phone 020 8554 4102 with your permission.
This consent form will be kept by the responsible Church Worker on the activity. Photographs/videos of this activity will be taken for display within the church.

I have read the notes above and I give my permission for the above named child to take part in this activity. *

Yes

Your name (parent or adult with parental responsibility) *

Your e-mail address *

Christmas Holiday Club 2011Registration Form

1. Details of child

2. Telephone numbers for emergency use

3. Other information

Christmas Holiday Club 2011
Registration Form