Mini Madams Consent Form
For guest attending a Birthday Party
Date of visit
-
Month
-
Day
Year
Date
Lead name of the party booking
First Name
Last Name
Name of child attending
First Name
Last Name
Childs age
Dietary Intolerances or Allergies we should be aware of:
Nuts
Fish
Peanuts
Gluten
Shellfish/Crustations
Milk
Wheat
Soybean
Eggs
Other
If your child has any other dietary intolerances or allergies please list below:
If you child has any medical conditions we should be aware of please list below:
Diabetes
Athlete's Foot
Asthma
Skin Sensitivity
Epliepsy
Impetigo
Herpes Simplex
Eczema
Veruca
Other
Is your child taking any medications at present? If so, please list below:
I give consent for medical aid to be used if necessary :
Yes
No
If you child has any of the following of please list below:
Autism
Light Sensitivity
Sensory Processing Disorder
Sensitive hearing
Other
If other, please list below:
I give consent for photo's and videography to be taken in Mini Madams to be used online and/or in marketing purposes including social media :
Yes
No
Parent or guardian contact details
First Name
Last Name
Contact number
-
Area Code
Phone Number
Secondary contact details
First Name
Last Name
Contact number
-
Area Code
Phone Number
Signature
Email
example@example.com
Submit
Should be Empty: