Purposeful Care in the Holidays Registration Form
Child’s Details
Name
Date of birth
Address
Parent/Guardian Details
Name
Home telephone
Mobile telephone
Email address
Emergency Information
Emergency contact name
Relationship to child
Telephone number
Alternative telephone number
Does this child have any
allergies, chronic illnesses or
medical conditions?
If yes please describe
Does this child require
emergency medication to be
held on his/her behalf?
If yes please provide
instructions for use
Informed consent acknowledgement
I give permission for suncream to be applied by club staff
Y/N
In an emergency club staff can provide medical treatment:
Y/N
In an emergency club staff can accompany my child to hospital:
Y/N
In an emergency my child can be transported by ambulance:
Y/N
I understand that children with any form of contagious illness will not be admitted
Y/N
I give consent for the school to take photographs of my child for use on the
school website and in other school publicity
Y/N
I understand that refunds will not be made for absence and cancellations
Y/N
I understand that children will only be accepted once a completed registration
form has been completed and payment has been received
Y/N
Signed
Date