Mokyklele Pupa: Registration Form

Registration Form

Child’s information
Name of child *

First Name Last Name
Date of Birth *

Day Month Year
Date
Male or Female *

Male Female
Religion
Languages Spoken
School/Nursery Attended
Name & Address
Home Address(of child) *

Street Address

Street Address Line 2

City County

Postcode
Any special requirements
Food/drink, Sun cream allergies etc
Tell us a bit about your child
Likes & dislikes, favourite subjects, activities etc
Photo Consent: I give permission for my child to be in pictures taken during activities to be used for evidence.(so we can share our activities done on the day with parents on Facebook, leaflets & www.mokyklelepupa.co.uk)

Signature Clear
Please note:

Please provide your child with a bottle of water with their name on it.

We will provide each child with a school folder on the first lesson. Please make sure your child brings this folder to every lesson.

For our younger kids please provide extra trousers/nappy in case your child has a toilet accident.

Child’s Medical information
Child’s medical/NHS number
Optional
GP Surgery/Doctors name *
GP/Doctors Address *

Street Address

Street Address Line 2

City County

Postcode
Details of any health issues: *
Allergies: *
Are all immunisations up to date

Yes No
In the event that my child is involved in a serious incident while at the club, I expect the delegated member of staff to contact me immediately using the contact information provided.In the event that my child requires immediate medical treatment or consent for emergency medical treatment by a hospital, I agree for the delegated member of staff to provide treatment contest to relevant treatments being given on my behalf.I understand that this authorisation will remain valid until I ask in writing for it to removed from this form. *

Signature Clear

Parent/Guardian information
Main Adult *

First Name Last Name
Main Email *
Main email address used for important information & invoices
Phone number *
Main adult address *

Street Address

Street Address Line 2

City County

Postcode
Second Adult

First Name Last Name
Email
Phone Number
Address

Street Address

Street Address Line 2

City County

Postcode
Persons Authorised to collect my child *
Full name & contact details
Emergency Contact details 1 *
Full name & contact number
Emergency Contact details 2 *
Full name & contact number
I confirm that all the information given above about myself & my child is correct and I agree that if any information changes then I will inform a manager to have these records updated *

Signature Clear
Name of person who signed above *

First Name Last Name
Should be Empty:

Registration Form