Balgaddy Child and Family Centre Consent Form
Consent form
I (parent/guardian) give my consent for my child to attend the below club in the Balgaddy Child and Family Centre
Parent / Guardian Details
*
First Name
Last Name
Child's details
*
First Name
Last Name
Please select which club your child is interested in attending
*
Youth Cafe
We CAN Learn with Lego!
Igniting Sparks
Homework Club
S.T.E.A.M.
Address
*
Street Address
Street Address Line 2
County
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of alternative contact
*
First Name
Last Name
Alternative contact number
*
Please provide a phone number for an alternative contact in the event of an emergency or if you are not available.
Format: (000) 000-0000.
Relationship to child
*
Childs Date of Birth
*
/
Month
/
Day
Year
Date
Childs Age
*
Please state if your child is on any medication or suffers from illness or allergies (e.g. asthma, diabetes, nuts)
*
Please share any other information you feel staff should be aware of (e.g. learning disability, sensory sensitivities, dietary requirements or any relevant information)
*
Collection when the club has ended
*
My child will be collected by me or a family member
My child will return to StartBright
My child can walk home themself
I give permission for pictures to be taken of my child in the club for displaying in the centre and for promotion of this programme on our social media
*
Yes
No
In the centre only
I give permission for my phone number to be added to a whatsapp group for the purpose of sharing information about the club my child is attending
*
Yes
No
How did you hear about the programme?
*
Signature
*
Submit
Should be Empty: