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1. CHILD INFORMATION
Child's Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Age:
*
Boy
Girl
Which age group will your child be attending? (please tick)
*
3-5 years (45 minutes)
6-8 years (60 minutes)
9-12 years (75 minutes)
2. PARENT / GUARDIAN DETAILS
Parent / Guardian Name:
*
First Name
Last Name
Relationship to Child:
*
Email Address:
example@example.com
Phone Number:
*
Format: 00000000000.
3. EMERGENCY CONTACTS
Please provide at least one emergency contact in addition to the parent/ guardian above.
Emergency Contact 1
Name:
*
First Name
Last Name
Relationship to Child:
*
Phone Number:
*
Format: 00000000000.
Emergency Contact 2 (Optional)
Name:
First Name
Last Name
Relationship to Child:
Phone Number:
Format: 00000000000.
4. MEDICAL INFORMATION
Does your child have any medical conditions?
*
Yes
No
If yes, please give details:
Does your child have any allergies?
*
Yes
No
If yes, please give details (e.g. food, insects, medication):
Is your child currently taking any medication?
*
Yes
No
If yes, please give details:
Please inform a coach of any medical needs before every session. Where is any medication kept?
5. PERMISSIONS
I give permission for my child to take part in KickStart MK sessions.
I give permission for photos/videos of my child to be taken for KickStart MK purposes (e.g. social media, website, promotional materials).
I do NOT give permission for photos/videos of my child.
I consent for my child to receive first aid if required.
I agree to receiving information about future events and sessions.
6. COLLECTION & DROP OFF
*
My child will be collected by a parent/guardian.
My child will be collected by the following authorised adult(s):
Name:
*
First Name
Last Name
Relationship:
*
My child may walk home on their own (for children aged 9+ only).
If collection arrangements change, I will inform a coach before the session.
7. ADDITIONAL INFORMATION
Is there any other information we should know about your child? (e.g. learning needs, confidence, anything that may help us support them)
8. AGREEMENT
Tick to agree to our KickStart terms
*
I confirm that the information provided is accurate and up to date.
I understand that KickStart MK coaches are not responsible for children outside of session times.
I agree to my child following the KickStart MK rules and behaviour expectations.
I understand that KickStart MK promotes inclusion and respect for all.
Parent / Guardian Signature:
*
Print Name:
*
Date:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
FOR OFFICE USE ONLY
Date Registered:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Age Group:
Medical Info Received:
Yes
No
Emergency Contacts Checked:
Yes
No
Consent Forms Checked:
Yes
No
Notes:
Submit
Should be Empty: