Page 1 of 9
HOLIDAY PLAY SCHEME BOOKING FORM
Please remember that parents/carers can only book a place for
their own child/children. Parents/carers are not guaranteed a
place until they have been specifically contacted and
notified.
Date (DD/MM/YY):
Time (HH/MM):
YOUR DETAILS
Title (please circle):
Miss Mr
Mrs
Ms
Other (please
specify):
First name:
Last name:
Address:
Post code:
Home telephone:
E-mail:
Relationship to child/children:
Ethnicity* (Please circle):
White
British
Greek
Cypriot
Mixed
White and
African
Mixed
Other
Other Black
African
Other Asian
White
Irish
Turkish
Any other
Black
background
Indian
Latin/South/Central
White
Irish
Traveller
White
Western
Europe
White
Eastern
Europe
White
Other
Turkish
Cypriot
Black
Caribbean
Kosovan
Nigerian
Pakistani
Prefer not to say
Gypsy/Roma
Somali
Bangladeshi
Other (please
specify):
Mixed
White and
Sierra
Leonian
Chinese
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Kurdish
Page 2 of 9
Greek
Black
African
Mixed
White and
Caribbean
Ghanaian
Borough (please circle):
Lambeth
Vietnamese
Southwark
CHILD 1 DETAILS
First name:
Last name:
Date of birth (DD/MM/YY):
Current age:
Gender (please circle):
Male Female
Ethnicity* (Please circle):
White
British
Greek
Cypriot
White
Irish
Turkish
White
Irish
Traveller
White
Western
Europe
White
Eastern
Europe
White
Other
Turkish
Cypriot
Black
Caribbean
Kosovan
Greek
Mixed
White and
African
Mixed
Other
Other Black
African
Other Asian
Any other
Black
background
Indian
Latin/South/Central
Nigerian
Pakistani
Prefer not to say
Gypsy/Roma
Somali
Bangladeshi
Other (please
specify):
Mixed
White and
Black
African
Mixed
White and
Caribbean
Sierra
Leonian
Chinese
Ghanaian
Vietnamese
Address (if different to above):
Postcode:
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Kurdish
Page 3 of 9
Borough (please circle):
Lambeth
Southwark
Please state any special needs/medical conditions (please also
notify the case manager if this is the case):
*Our Children's Centre funding requires us to provide statistical information about the ethnic origin of children
using our services. We will not use this data for any other purposes.
All personal information given on this form will be held and used in accordance with the Data Protection Ac t
1998.
CHILD 2 DETAILS
First name:
Last name:
Date of birth (DD/MM/YY):
Current age:
Gender (please circle):
Male Female
Ethnicity (Please circle):
White
British
Greek
Cypriot
White
Irish
Turkish
White
Irish
Traveller
White
Western
Europe
White
Eastern
Europe
White
Other
Turkish
Cypriot
Black
Caribbean
Kosovan
Greek
Mixed
White and
African
Mixed
Other
Other Black
African
Other Asian
Any other
Black
background
Indian
Latin/South/Central
Nigerian
Pakistani
Prefer not to say
Gypsy/Roma
Somali
Bangladeshi
Other (please
specify):
Mixed
White and
Black
African
Mixed
White and
Caribbean
Sierra
Leonian
Chinese
Ghanaian
Vietnamese
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Kurdish
Page 4 of 9
Address (if different to above):
Postcode:
Borough (please circle):
Lambeth
Southwark
Please state any special needs/medical conditions (please also
notify the case manager if this is the case):
CHILD 3 DETAILS
First name:
Last name:
Date of birth (DD/MM/YY):
Current age:
Gender (please circle):
Male Female
Ethnicity (Please circle):
White
British
Greek
Cypriot
Mixed
White and
African
Mixed
Other
Other Black
African
Other Asian
White
Irish
Turkish
Any other
Black
background
Indian
Latin/South/Central
White
Irish
Traveller
White
Western
Europe
White
Eastern
Europe
Turkish
Cypriot
Black
Caribbean
Kosovan
Nigerian
Pakistani
Prefer not to say
Gypsy/Roma
Somali
Bangladeshi
Other (please
specify):
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Kurdish
Page 5 of 9
White
Other
Greek
Mixed
White and
Black
African
Mixed
White and
Caribbean
Sierra
Leonian
Chinese
Ghanaian
Vietnamese
Address (if different to above):
Postcode:
Borough (please circle):
Lambeth
Southwark
Please state any special needs/medical conditions (please also
notify the case manager if this is the case):
PLEASE COMPLETE A SECOND BOOKING FORM IF YOU HAVE MORE THAN 3
CHILDREN.
Please indicate here if you have filled in more than one form
EMERGENCY CONTACTS for all children listed above
Emergency contact 1
Name:
Phone number:
Relationship to child:
Emergency contact 2
Name:
Phone number:
Relationship to child:
ATTENDANCE
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Page 6 of 9
Standard session (£25): 9am-4pm, Extended session
(£30): 8am-6pm
Dates Week 1
Please tick
STANDARD days
child/children
will attend
Please tick
EXTENDED days
child/children
will attend
Amount of
children
(please circle)
Monday
1/2/3/4/5
Tuesday
1/2/3/4/5
Wednesday
1/2/3/4/5
Thursday
1/2/3/4/5
Friday
1/2/3/4/5
Dates Week 2
Please tick
STANDARD days
child/children
will attend
Please tick
EXTENDED days
child/children
will attend
Amount of
children
(please circle)
Monday
1/2/3/4/5
Tuesday
1/2/3/4/5
Wednesday
1/2/3/4/5
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Page 7 of 9
Thursday
1/2/3/4/5
Friday
1/2/3/4/5
Dates Week 3
Please tick
STANDARD days
child/children
will attend
Please tick
EXTENDED days
child/children
will attend
Amount of
children
(please circle)
Monday
1/2/3/4/5
Tuesday
1/2/3/4/5
Wednesday
1/2/3/4/5
Thursday
1/2/3/4/5
Friday
1/2/3/4/5
Dates Week 4
Please tick
STANDARD days
child/children
will attend
Please tick
EXTENDED days
child/children
will attend
Amount of
children
(please circle)
Monday
1/2/3/4/5
Tuesday
1/2/3/4/5
Wednesday
1/2/3/4/5
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Page 8 of 9
Thursday
1/2/3/4/5
Friday
1/2/3/4/5
Dates Week 5
Please tick
STANDARD days
child/children
will attend
Please tick
EXTENDED days
child/children
will attend
Amount of
children
(please circle)
Monday
1/2/3/4/5
Tuesday
1/2/3/4/5
Wednesday
1/2/3/4/5
Thursday
1/2/3/4/5
Friday
1/2/3/4/5
Dates Week 6
Please tick
STANDARD days
child/children
will attend
Please tick
EXTENDED days
child/children
will attend
Amount of
children
(please circle)
Monday
1/2/3/4/5
Tuesday
1/2/3/4/5
Wednesday
1/2/3/4/5
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Page 9 of 9
Thursday
1/2/3/4/5
Friday
1/2/3/4/5
KEEP UP TO DATE
I would like to sign up to the Coin Street e-list to keep up to date
with free and local events and activities (please circle):
Yes
No
IMPORTANT – PLEASE READ THE FOLLOWING BEFORE SUBMITTING THIS
FORM
Yes I give consent for my child/children to be
photographed/filmed for education & information purposes
Yes I give consent for my child/children to be
photographed/filmed for promotional purposes
No, I do not consent for my child/children to be
photographed/filmed
I confirm that I have legal responsibility for all children
listed on this form and have filled in this form with
information correct to the best of my knowledge (please tick
to confirm)
PLEASE NOTE: Once your booking has been confirmed, you cannot cancel
or make changes to the requested dates of the programme.
Please post or deliver your booking form to the address below for
the attention of Carine Leung, or email [email protected]
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org