Xtra Time Community Give Back

Name:*

First NameLast Name

E-mail:*

example@example.com

Contact 1:*

Mobile number

Contact 2:*

Mobile number

Full Address:*

Street Address

Street Address Line 2

CityCounty

Postcode

Please complete the form below so that we can assist you in the best way possible. Confidentiality guaranteed.

Please give us a brief breakdown of your current situation and why you need support.

Please give us information that will help us understand your situation.

How many children do you have that need support?

Child 1 Full Name:*

First NameLast Name

Child 1 School:

Child 1 Age:*

Child 1 Shoe Size

Child 1 Clothes / Dress Size

Child 1: Please give us a brief description of your child's Needs: For example, shoe size, clothes / dress size, favourite sport / activity. Please give as much information as possible.

Any additional information that will help us understand your child's needs better

Child 2 Full Name:*

First NameLast Name

Child 2 School:

Child 2 Age:*

Child 2 Shoe Size

Child 2 Clothes / Dress Size

Child 2: Please give us a brief description of your child's Needs: For example, shoe size, clothes / dress size, favourite sport / activity. Please give as much information as possible.

Any additional information that will help us understand your child's needs better

Child 3 Full Name:*

First NameLast Name

Child 3 School:

Child 3 Age:*

Child 3 Shoe Size

Child 3 Clothes / Dress Size

Child 3: Please give us a brief description of your child's Needs: For example, shoe size, clothes / dress size, favourite sport / activity. Please give as much information as possible.

Any additional information that will help us understand your child's needs better

Child 4 Full Name:*

First NameLast Name

Child 4 School:

Child 4 Age:*

Child 4 - Shoe Size

Child 4 - Clothes / Dress Size

Child 4: Please give us a brief description of your child's Needs: For example, shoe size, clothes / dress size, favourite sport / activity. Please give as much information as possible.

Any additional information that will help us understand your child's needs better

Child 5 Full Name:*

First NameLast Name

Child 5 School:

Child 5 Age:*

Child 5 Shoe Size

Child 5 Clothes / Dress Size

Child 5: Please give us a brief description of your child's Needs: For example, shoe size, clothes / dress size, favourite sport / activity. Please give as much information as possible.

Any additional information that will help us understand your child's needs better

Child 6 Full Name:*

First NameLast Name

Child 6 School:

Child 6 Age:*

Child 6 Shoe Size

Child 6 Clothes / Dress Size

Child 6: Please give us a brief description of your child's Needs: For example, shoe size, clothes / dress size, favourite sport / activity. Please give as much information as possible.

Any additional information that will help us understand your child's needs better

Do any of your children have any medical Condition(s):*

Do any of your children have any SEN:*

Does your child have any SEN (Special Educational Needs)?

Details of children's Medical Condition(s) / SEN:*

Please provide details of any medical conditions.and/or Special Additional Needs. For example:Asthma and/or ASD etc

Do you give consent to Xtra Time Kidz Club to take pictures or videos of your child which will ONLY be used for marketing purposes (Social media platforms, www.xtratime.co.uk, flyers and other advertising purposes)?*

YesNo

Do you follow us on social media?*

YesNo

Thank you for following us on social media.

Please Like, Share and Subscribe to our social media platforms by clicking on to the images below.

How Did You Hear About Us?*

Other: How Did You Hear About Us:*

Other way you heard about us:

Please have a look at our website www.xtratime.co.uk to see the various services we offer. If there is any service you would like to enquire about, please let us know so that we can see if we can support you. You can also email sportsservices@xtratime.co.uk or call: 07746945903.

Signature:

GDPR

YES

Date