Child's Full Name

Child's Date of Birth

Child's Age

Child's School

Child's School Year

Your Address: House Number/Name

Your Address: Line 1

Your Address: Line 2

Your Address: Village/Town

Your Address: Post-Code

Any known allergies or conditions:

Emergency Contact Name

Telephone Number

Your Email

GP's name

GP's Telephone

Days attending holiday club

MondayTuesdayWednesdayThursdayFridayFriday lunch BBQ

Throughout the week we will be taking photographs to use for the publicity of future holiday clubs/church events. If you do give permission for us to take photographs of your child please tick this box. This person has opted in
(Photographs will never be labelled with children's names)

I confirm that the above details are complete and correct to the best of my knowledge.
In the unlikely event of illness or accident, I give permission for any appropriate first aid to be given by the nominated first-aider. In an emergency, and if I cannot be contacted, I am willing for my child to be given hospital treatment, including anaesthetic if necessary. I understand that every effort will be made to contact me as soon as possible.

Parent/Guardian Name

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