Try High Holiday Club Booking Form
(October 2024)
*PLEASE READ* We expect your child to attend each of the 4 days (of course there are exceptions but please let us know in advance). This is not a guarantee of your place, we prioritise children accessing Free School Meals. However we do have places available for free for other children and/or we may ask for a small donation of £10 for the week.
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Child's Details
First Name
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Last Name
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Is your child accessing benefits related free school meals?
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Yes
No
Unsure
School
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Does your child have a Disability?
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Please Select
Not Applicable
Hearing (Deaf, Partially Deaf, Hard of Hearing)
Learning Difficulty (e.g. Dyspraxia, Dyslexia, Dyscalculia, ADHD)
Learning Disability (e.g. Down's Syndrome, Asperger's Syndrome, MLD, SLD)
Mental Health Condition (e.g. Anxiety, Depression, Schizophrenia, Dementia)
Physical - Ambulant (I do not use a wheelchair)
Sight (Blind or Partially Sighted)
Other
Prefer Not To Say
Yes
No
Is your child on the SEN Register?
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Please Select
Yes
No
Unsure
Address
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Street Address
Street Address Line 2
City
Area
Postcode
Ethnicity
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White English
White British
White Welsh
White Scottish
White Irish
White Other
Gypsy/Irish Traveller
White and Black Caribbean
White and Black African
White and Asian
Asian
Asian British
Indian
Pakistani
Chinese
Bangladeshi
Black
Caribbean
African
Black British
Any other Black/Caribbean/African Background
Arab
Any other ethnic group
Gender
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Child's DOB
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/
Day
/
Month
Year
Date
Parent/ Guardian Name
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First Name
Last Name
Parent/ Guardian Phone Number
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Is English the child's first language?
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Please indicate any additional support needs?
Medical and Sensitive Information
Does your child have any physical health conditions that we need to be aware of?
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Does your child have any allergies we need to be aware of? If yes, how serious is it?
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Is your child currently taking any medication that we need to be aware of? including Asthma Inhalers & Epi-Pens
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Is there anything we need to know so we can support your child?
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Does your child have any joint problems (Including neck, back & hip) that could be made worse by exercise, including jumping and landing?
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Yes
No
Has your child's doctor ever said that they have a heart condition and that they should only do physical activity recommended by a doctor?
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Yes
No
Does your child suffer from shortness of breath at any time or a respiratory condition that would prevent them from doing physical activity?
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Yes
No
Does your child ever feel faint or have spells of dizziness?
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Yes
No
Are there any reasonable adjustments we need to make?
Emergency Contact Details - Parent/Guardian
Emergency Contact #1
Full Name:
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First Name
Last Name
Relationship to Young Person:
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Preferred Telephone
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Second Telephone
E-mail:
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Emergency Contact #2
Full Name:
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First Name
Last Name
Relationship to Young Person:
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Preferred Telephone
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Second Telephone
E-mail:
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Consent - To be completed by parent/guardian
General Consent
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I confirm that I consent to my son/daughter taking part in Try High Holiday Club for the dates specified above.
Correct Medical and Sensitive Information
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I confirm that I have disclosed all relevant medical and sensitive information and am content that Invictus Wellbeing and delivery partners have access to this information.
Further Contact
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I agree to be contacted further (future projects, newsletters etc).
I don't agree to be contracted further.
Media Consent
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I agree to photographs and film footage containing my son/daughter to be used in marketing/social media.
I do not agree to photographs and film footage containing my son/daughter to be used in marketing/social media.
Print Name
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First Name
Last Name
Submit Form
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