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

Holiday Club for 5-10 year olds

Wednesday 24^th & 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.