Holiday Club Registration Form

Registration Form
Child Information
Child's Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemalePrefer not to say
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
#1
Name*

First NameLast Name
Relationship to child *
Mobile Number*

Area CodePhone Number
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
#2
Name*

First NameLast Name
Relationship to child *
Mobile Number*

Area CodePhone Number
E-mail*
example@example.com
Address (if different to #1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip pCodeCountry
Emergency Information (Please choose someone different to parent/guardian where possible)
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Does the child have any disabilities or SEN If yes, please describe, including how we can assist with these needs.*
Is the child prescribed an inhaler? If yes, please explain any instructions.*
About my child. If you would like to tell us about your child's personality, likes and/or dislikes please include here.
Confirmation of details given

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Clear
We use social media platforms to show you photographs/videos of what your child has been up to while attending the club. We avoid including children's faces to the best of our ability. Please tick below if you do/do not consent to your child being included in these posts. *

I consentI do not give my consent
Should be Empty:

Registration Form

Child Information

#1

#2