Sign Up/Consent Form

Adult/Guardian Details

First NameLast Name

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

City

Child's Details

First NameLast Name

Age

Which programme are you registering your child's for?

Please state if your son/daughter is on any medication or suffers from any illness (eg. asthma, allergies, diabetes)

Does your child have any additional needs we should be aware in order to support their participation

I give permission to my son/daughter's photo/video to be taken for the purpose and promotion of the KICK Programme and 6-12 Project. Some photo's/videos my be posted on SDCP's and KICK's social media platforms and websites

Son/daughter date of birth

Please select how you would like your child to be collected?

Alternative contact person ( in case of an emergency or if you are not available)

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to child

I, hereby consent to my son/daughter taking part in KICK/KICK 101/JEDI Fitness/Gymnastics/Summer Camp session. Sumemr Camp includs off site activities such us trip to Jump Zone Liffey Valley and Climbing Centre Tallagh and understand and agree that he/she participates in sessions under the instruction of KBI qualified coaches entirely at his/her own risk. I have considered the nature of such sessions and have discussed them with him/her. I am satisfied that he/she is sufficiently responsible and competent to assume responsibility for his/her safety under the supervision of a KBI qualified coach. I confirm that he/she does not have any medical disability or medical condition (not disclosed above) that could affect his/her ability to participate safely in KICK/KICK 101/JEDI Fitness/Gymnastics/Summer Camp sessions.

Signature

Date

Parent/Guardian Sign Up/Consent Form