SOCOPA Tuition Programme

SOCOPA Tuition Programme
First Name and Last Name of Young Person Attending

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Siblings Attending The Project
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Mother
Mother Contact Number
Please enter a valid phone number.
Name of Father
Father Contact Number
Please enter a valid phone number.
Emergency Contact Details
Name of Emergency Contact
Emergency Contact Number
Please enter a valid phone number.
Relationship To Child
Medical Details
Doctor's Name
Doctor's Contact Number
Please enter a valid phone number.
Doctor's Address
Do you consent to your child receiving medical/dental treatment in an Emergency situation ?
Is your child allergic to anything?
Please give details of anything your child cannot/does not eat:
Is there any additional medical conditions/issues? (e.g. health problems, emotional or behavioural concerns, etc)
Further Information
Can your child swim?
Do you give permission for video or photographs to be taken of your child (for Publicity purposes only)?
Do you give permission for your child to use a computer and have access to the Internet?
Name(s) of person(s) responsible for arrival and collection of young at the SOCOPA.
Declaration
I agree to my son/daughter participating in Young Ecology Project and the activities run by the SOCOPA. I understand that every care will be taken to ensure the health, safety and welfare of my child.

I realise and accept that in the event of my child’s behaviour adversely affecting the safety of the activity, the organisers reserve the right to return my child home.

I understand that the SOCOPA cannot be held responsible for damage or loss to my child’s property whilst attending the Project.

I agree that the above details are correct and up-to-date and that if any of the details change I will inform SOCOPA.
Consent
Date of Consent

DayMonthYear
Date
Should be Empty:

SOCOPA Tuition Programme

Emergency Contact Details

Medical Details

Further Information

Declaration