3D Holiday Activity Programme - (HAF) Spring 2022 Registration Form

3D Holiday Activity Programme - (HAF) Spring 2022 Registration Form
Student Information
Child's Name

First NameLast Name
Year Group
School Currently Attending
Gender
Address

Street Address

Street Address Line 2

City

Postcode
Date of Birth

DayMonthYear
Date
Does your child have special educational or health needs? (you can ask your school if you are not sure)

YesNo
If yes, please describe
Is your child eligible for Free School Meals?

YesNo
Dietry Requirements

NoneVegetarianVeganHalalOther
If other, please give further details
Parent(s)/Guardian(s) Information
Parent/Guardian 1

First NameLast Name
Relationship
Phone Number

Phone Number
Email
example@example.com
Parent/Guardian 2

First NameLast Name
Relationship
Phone Number

Phone Number
Email
example@example.com
Emergency Information

Please give details of a an adult relative or family friend to contact if parents are not available
Name

First NameLast Name
Relationship
Phone Number

Phone Number
Health Information
Family Doctor

First NameLast Name
Surgery Name
Phone Number

Area CodePhone Number
Please let us know if this child have any allergies*
List medications if this child is currently taking*
Has this child had any serious illnesses or operations?

YesNo
If yes, please describe
Can this child take part in regular physical activities?

YesNo
Do you want to add any further information?
Permissions

The 3D Holiday School may take videos, pictures or conduct interviews with the children for promotional material.
I give permission for my child's video, picture or voice to be used for promotional material.

Yes to allVideo onlyPicture onlyAudio onlyNo to All
By signing or submitting this form you consent to the programme provider sharing your information with Derby City Council, your school and your Doctor as required.
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3D Holiday Activity Programme - (HAF) Spring 2022 Registration Form

Student Information

Parent(s)/Guardian(s) Information

Emergency Information

Health Information

Permissions