Please select *

Boy

Girl

School and year group (from August 2012), for example, Braybrook– KS2 *

Child’s school attended *

Parent/Carer Information

Phone number(s) Home Mobile Work *

Person collecting each day

Parent/carer *

Yes

provide details

Parent/carer *

Yes

person collecting *

Yes

GP’s name & surgery GP’s phone number *

Child’s known allergies or conditions *

Any dietary requirements

Does your child have an epi pen *

Yes

Is there anything we need to know about your child to support your child during their time at holiday club/HAF

Does your child have any specific SEND needs? *

Yes

If the answer above is yes, what needs do they have and how can we support them.

Do you give permission for this child to have his/her photograph taken? *

Yes

Do you give permission for this child’s and your details to be entered on the holiday club database? *

Yes

I confirm that the above details are complete and correct to the best of my knowledge. Please register this child for Herlington pre-school Holiday Club.

In the unlikely event of illness or accident, I give permission for any appropriate first aid to be given by the nominated first-aider. In an emergency, and if I cannot be contacted, I am willing for this child to be given hospital treatment, including anaesthetic if necessary. I understand that every effort will be made to contact the people named above as soon as possible.

Relationship to child *

Holiday Club’s Registration Form