DKHAP Play scheme Form

DATE: Monday 17th February-Friday 21st August

DROP OFF: 9.00 am

PICK UP: 6.00pm

COST: £25 per day, per child. 3rd child attends free of charge

Information of Child/ren

1.Childs name

First NameLast Name

Gender

MaleFemale

School year

Birth Date

MonthDayYear

Allergies, illness, Challenging behaviour,or medical conditions? If yes, please describe.

2.Childs name

First NameLast Name

Gender

MaleFemale

School year

Birth Date

MonthDayYear

Allergies, illness, Challenging behaviour,or medical conditions? If yes, please describe.

3.Childs name

First NameLast Name

Gender

MaleFemale

3.Birth Date

MonthDayYear

School year

Allergies, illness, Challenging behaviour,or medical conditions? If yes, please describe.

Address

Street Address

Street Address Line 2

City

Post code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Mobile number

Address

Street Address

Street Address Line 2

CityState / Province

Post codeCountry

E-mail

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Address

Street Address

Street Address Line 2

CityState / Province

Post codeCountry

Alt. Phone Number

BOOKING INFORMATION

Week 1

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 1

	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 2

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 3

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 4

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 5

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 6 ( To be confirmed )

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

To pay via bank transfer please use the below details:

HSBC

Sort Code: 40-02-01

Account number: 71536931

If you could please reference it with your childs name & playscheme that would be great.

REFUNDS AND CANCELLATIONS POLICY

There will be no credits or refunds issued for absences through sickness, special classes etc. unless under exceptional circumstances. The initial deposit in non refundable

If you choose to terminate your child’s place during the scheme, Dog Kennel Hill Adventure Playground are not able refund you.

TRAVELLING HOME ALONE

Only for Children aged 12 and above

Time of departure

Signature of permission

FAMILY GP DETAILS:

Doctors name

First NameLast Name

GP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Do you give permission for staff to take photos of your child?*

	yes	no
1. May we use your child’s image in our printed promotional publications?
2. May we send out your child’s image with our press releases?
3. May we use your child’s image on our website?
4. May we record your child’s image on our promotional videos?
5. May we record your child’s image on our Facebook/Instagram page?

DATA PROTECTION

If you are concerned about how the council is using your data, please contact Southwark councils Data Protection Officer via dpo@southwark.gov.uk or on 020 7525 5000. More information about your rights is available on Southwark councils website, or via the Information Commissioner (www.ico.org.uk).

Would you like us to use this form for your child/ren for all future play schemes?

YesNo

Confirmation

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.

Signature

REGISTRATION FORM