Easter Holiday Club

Please complete the following form with as much information as possible in order for us to provide the highest quality care for your child.

Easter Holiday Club Enrolment Form

Child's Details Child's Details

Child's Name:

Preferred Name:

Date of Birth and Current Age:

School or Pre School Attended:

Child's First Language:

Parent/Guardian Details 1st Emergency Contact Parent/Guardian Details 1st Emergency Contact

Parent/Carers Name:

Email Address:

Home Address

Post Code:

Emergency Contact Number:

Work Contact Number:

Does your child normally live at this address? Does your child normally live at this address? Yes No

Does this person have parental responsibility? Does this person have parental responsibility? Yes No

Relationship to child:

2nd Emergency Contact 2nd Emergency Contact

2nd Contact Name:

Relationship to child:

Does this person have Parental Responsibility? Does this person have Parental Responsibility? Yes No

2nd Contact Mobile Number:

2nd Contact Work Number:

2nd Contact Email:

Child's Health Information Child's Health Information

Doctors Surgery Child is registered at:

Doctors Surgery Phone Number:

Does the child have any Allergies or Intolerances?

Does the child have an EpiPen?

Please provide information about Allergies or Intolerances:

Does the child have any Dietary Requirements?

Can a member of staff apply a plaster to your child if needed?

In an Emergency do you give staff permission to go with your child in an ambulance to hospital? In an Emergency do you give staff permission to go with your child in an ambulance to hospital? Yes, I would like someone to go with my child No, I do not give permission for someone to go with my child

Is there anything that upsets or worries your child that we should know about?

I give permission for my child to: I give permission for my child to:

Go for walks around the local area including the woods Go for walks around the local area including the woods Yes, I give permission No, I do not give permission

Visit the local supermarket Visit the local supermarket Yes, I give permission No, I do not give permission

Photographs to be published on Social Media Photographs to be published on Social Media Yes, I give permission No, I do not give permission

My child to have their face painted My child to have their face painted Yes, I give permission No, I do not give permission

Is there any other information we should know about your child?

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