Holiday club booking form
Christmas 2021
Children’s details
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
Age
School attended?
School address
Doctors details
Please include all details
Doctors Name
First Name
Last Name
Surgery address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctors phone number
Additional and medical needs
Does your child have any allergies?
Yes
No
Please provide details
Does your child have any additional needs?
Yes
No
Type option 4
Please provide details
Is there any foods your child cannot eat due to cultural or religious beliefs?
Yes
No
Please provide details
Does your child take any regular medication?
Yes
No
Please provide details
Medical consent
Please indicate if you are happy for your child to receive emergency medical treatment
I am happy for my child to receive the following treatments:
Simple first aid including but not limited to plasters
Emergency medical treatment by ambulance/ medical professional
Calpol in the event of fever
Blood transfusions (medical professional)
Parents details
Parent 1
First Name
Last Name
Phone number
Email
example@example.com
Parent 2
First Name
Last Name
Phone number
Email
example@example.com
Emergency contact details
Please provide 2
Emergency contact 1
First Name
Last Name
Phone number
Emergency contact 2
First Name
Last Name
Phone number
Photographs and social media
Type a question
Photographs for in club use
Photographs for social media/advertising
Videos for in club use
Videos for social media/ advertising
Dates requested
Please note funded places are available 20th- 23rd December 10-4, extended hours are charged at £5 per hour.
Type a question
HAF funded
10-4
Full day 9-5
Full day early drop off
Full day late pick up
Full day early and late
20/12
21/12
22/12
23/12
24/12
29/12
30/12
31/12
03/01
04/01
Does your child receive free school meals?
Yes
No
Any other relevant information?
By signing you are agreeing to our terms and conditions as well as indicating all information included is accurate.
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