Year 5 & 6 - Fund Raiser

Please complete the booking form below to secure your child's place for this Xtra Time Kidz Club Fund Raiser.

Finish Time:*

I would like to book The Fund Raiser

Tuesday 18th June 2024

Open to boys & girls from Year 3 to Year 6

*Prizes, trophies, medals, and certificate to be won*

£5.00 (The Fund Raiser will run throughout the school day)

Activities Include (This can vary):

Inflatable Dart Board (Target Practice)
Ball Launcher
Speed Gun
Obstacle Course and much more.

Please note: The year 3 & 4 fundraiser is at 1.10pm-2.10pm & the year 5 & 6 fundraiser is at 2.10pm-3.10pm.

Child's Full Name:*

First NameLast Name

Child's School:

Child's Year:*

Child's Class:*

Child's Teacher:*

Medical Condition(s):*

It has been advised by our First Aid Trainers that we should administer a second dose of EpiPen 5-15 minutes after the first dose if the child does not feel better. It also allows critical time for the ambulance crew to get to the session. If your child requires an EpiPen, your child must have TWO EpiPen's with them at all times. By ticking this box you are confirming that you will send your child in with two EpiPen's. Failure to do so will result in Xtra Time sending your child to the school office. Your child will not be able attend the session until they have two EpiPens. This is to safeguard your child and Xtra Time Kidz Club Staff.*

I confirm that I have read and understand the above.

Does Your Child Have Any SEN:*

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

Details of Medical Condition(s) / SEN:*

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

Parent/Guardian Name:*

First NameLast Name

Parent/Guardian E-mail:*

example@example.com

Emergency Contact 1:*

Mobile number

Emergency Contact 2:*

Mobile number

Late booking fee

Applied £5.00

Payment Method:*

Bank Transfer - Please follow the instructions below

Please make your booking payment in full to the account below:

It is soley the parent/carers responsibilty to make the booking payment in full. If your child's payment has not been made in full to the account specified above, we cannot secure your child's booking.

Once you have made your payment in full, please include your payment reference and payment date below.

ALL PAYMENTS MUST ONLY BE PAID INTO THE ACCOUNTS LISTED BELOW AS EACH XTRA TIME SERVICE HAS ITS OWN SPECIFIED ACCOUNT. THIS HELPS US TO ALLOCATE YOUR PAYMENT.

Payment Date:*

Date

Payment Reference:*

Payment Reference

Please attach a screenshot of your payment below.*

If you are unable to attach a screenshot of your payment, please write the details of your payment on a piece of paper stating the reference, date and amount paid. Providing this enables our finance team to easily find your payment and avoid the need to contact you.

Additional Comments:

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

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

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Please sign below to confirm your booking.

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YES

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Date

EpiPen.