Registration form please complete one form for each child and return it to Acorn Community Church, Oxford Street, Whitley Bay, ne26 1AE. Please print



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Date29.01.2017
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TypeRegistration form
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Holiday Club for 5-10 year olds

Wednesday 24th & Thursday 25th July 2013, 10am -12noon each day
REGISTRATION FORM
Please complete one form for each child and return it to Acorn Community Church, Oxford Street, Whitley Bay, NE26 1AE. Please PRINT clearly.


DETAILS OF CHILD

Full name


Address


Contact Phone number


School /year


Date of birth

PARENTS/GUARDIAN

Full Name


Address ( if different from above)


Phone


Mobile

Email


MEDICAL INFORMATION – if answering YES, please give details

Does he/she suffer from any on-going or recurring illness?




Does he/she take any regular medication?





If YES, does he/she self medicate?

Note: we do not administer any medication.






Any phobias, disabilities or known allergies?





Has he/she been immunised against tetanus?




Any special dietary requirements?





Any other information we should be aware of?





PERSON(S) COLLECTING FROM CLUB

1.Name
Mobile

Relationship to child

2.Name
Mobile

Relationship to child



Statement of consent – to be signed by Parent/Guardian
I give permission for my child as named above to attend the On Your Marks Holiday Club organised by Acorn Community Church, Whitley Bay. My child will remain within the premises/group at all times and is not allowed to leave the premises/group unless accompanied by his/her parent/guardian or one of the named adults to whom I/we have given permission.

If it becomes necessary for my child to be given urgent medical treatment and I cannot be contacted by phone or nay other means to authorise this, I hereby give my general consent to any medical treatment judged necessary and urgent by a medical practitioner and I authorise the leader in charge to sign any document required by hospital or other authorities.


Signed ___________________________________________________________ Date _______________________
Print Name _______________________________________________________
Due to the nature of the children’s work we sometimes wish to take photographs of the various activities taking place. These are for use in the church notices, literature or website. If you would prefer that any photos of your child were NOT used in this way, please tick this box.
We take child protection issues very seriously. Any concerns should be raised with Julia Wilthew, Safeguarding Officer (tel: 07984549000). The above information will be stored on a computer database for the sole purposes of running the Holiday Club and to inform you of any similar future activities.


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