Record Breakers Holiday Club

Registration Form
Thank you for signing up for Record Breakers Easter Holiday Club

Tuesday 15th to Thursday 17th April 2025

10.00 am - 12.00 pm

We will be continuing our theme of wacky records so be prepared to attempt some records and take part in awesome challenges.

The holiday club will take place at

The Station Youth Centre

(Next to Rio)

Mill Street

Ottery St Mary

EX11 1AH
Name of Parent*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Name of Child*

First NameLast Name
Age (at time of holiday Club)*
Date of Birth*
Any special/medical/dietary needs we need to know about.*
Write none if not applicable
What days will your child be attending?*

TuesdayWednesdayThursday
Name of second Child

First NameLast Name
Age (at time of holiday Club)
Date of Birth
Any special/medical/dietary needs we need to know about.
What days will your child be attending?

TuesdayWednesdayThursday
Name of third Child

First NameLast Name
Age (at time of holiday Club)
Date of Birth
Any special/medical/dietary needs we need to know about.
What days will your child be attending?

TuesdayWednesdayThursday
Emergency Contact*

First NameLast Name
Telephone Number*

Area CodePhone Number
Relationship to Child*
Please tick the relevant statements*

I give permission for my child(ren) to attend Holiday ClubI give permission for my child to have medical treatment by trained First Aiders (or the hospital) if needed.I give permission for photographs/videos to be taken of my child(ren). These will only be used for limited O6 purposes including internal use, website, holiday club presentations and holiday club publicity.I give my permission for this data to be stored and used for contact only purposes when the next holiday club or similar activities happen.*
* All data will be kept on record until the young person is too old for O6 activities (18 years old) or we are told to remove it, whichever is sooner.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Registration Form