Registration Pack

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Registration Pack
Club Vale Breakfast & After School Club
07905 394 029
[email protected]
Club Vale Holiday Club Registration Form
PLEASE NOTE HOLIDAY CLUB IS ONLY AVAILABLE FOR CHILDREN IN CURRENT RECEPTION to YR 6
Childs full name:
Name Child is known by:
Age of child:
Date of Birth:
Address:
Male / Female :
Postcode:
Telephone Number:
Email Address:
School your child attends:
Please ensure that you provide contact numbers for at least 3 people who can be contacted in an
emergency
Parent/guardian 1
Mr/ Mrs/ Miss/ Ms
Address:
Relationship to Child:
Parental responsibility:
Place of work:
Occupation:
Email:
Work telephone no:
Mobile number:
Parent/guardian 2
Mr/ Mrs/ Miss/ Ms
Address:
Relationship to Child:
Parental responsibility:
Place of work:
Occupation:
Email:
Work telephone no:
Mobile number:
Yes/No
Yes/No
Please ensure this contact is within easy reach of the school
Emergency contact 1
Mr/Mrs/Miss/Ms
Address:
Relationship to Child:
Daytime telephone no:
Mobile number:
Name of person who will collect:
Name of 2nd person who will collect:
Parents/guardians must notify Club Vale of any changes to these details immediately
Page 1
Childs Doctor:
Address:
Telephone No:
Are all immunisations up to date:
Date of last tetanus vaccination:
Social worker name/tel no:
Health visitor name/tel no:
Does your child have a statement of
Y/N
special needs or currently in the process
of a statutory assessment:
Please give specific details of the statement/assessment below and if necessary please use additional paper:
(we will call you to discuss this in more detail)
Specific requirements for your child
Does your child have any of the following:
Asthma
Y/N
Hayfever/Eczema
Convulsions/fits
Y/N
Migraines
Diabetes
Y/N
Heart condition
Epilepsy/fits
Y/N
Special Dietary requirements
Food Allergies
Y/N
Other
Does your child take any regular medication
Y/N
If you have answered Yes to any of the above please give details:
Y/N
Y/N
Y/N
Y/N
Y/N
Does your child have any allergies (Please make careful note of action required)
Does your child have an Epipen? Yes/No
Please note: Two Epipens will be required at the club before your child can start
(if your child has an Epipen, we will book a date for a meeting to complete an individual Health Care Plan with the club manager as per
our Medication policy and procedure)
For your child’s health and welfare they will only be allowed in the setting with their medication
Details of any procedures of foods that are prohibited for medical, religious, cultural or other reasons
Childs religion/culture:
Nationality/language:
Anything else you think Club Vale should know about your child (likes/dislikes, behaviour, circumstances etc.
Parents/guardians must notify Club Vale of any changes to these details immediately
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PERMISSIONS/AGREEMENTS:
I consent for my child to receive emergency medical treatment, if required and permitted by a registered
practitioner in my absence. I give permission for any required treatment, including general anaesthetic, blood
products etc. as deemed by the medical profession at that time.
Parents/carers signature:___________________________________________________________
Photographs may be taken of your child please sign below to confirm you give permission for Club Vale to use
them for ‘Media, adverts, brochures, our website and personal displays’
Parents/carers signature:___________________________________________________________
Please sign to confirm that your child can have face paints
Parents/carers signature:___________________________________________________________
At Club Vale we offer a DVD viewing during the session. (PG rated films are assessed and are only offered if
age appropriate, I give consent for my child to view a PG rated film.
Parents/carers signature:___________________________________________________________
We request that parents/carers send sun cream for their children to be applied during the day. Please sign to
confirm we can apply their own sun cream to your child if they require assistance. Please apply prior to
attendance and send in named bag or bottle.
Parents/carers signature:___________________________________________________________
I agree to my child taking part in the organised outings
Parents/carers signature:___________________________________________________________
I agree to my child taking part in water games (you may wish to provide a spare t-shirt)
Parents/carers signature:___________________________________________________________
Please note that no unauthorised person will be allowed to collect your child. No child under the age
of 16 is allowed to collect a child from the club
I confirm I have read, understood and will adhere to the terms and conditions as outlined on the booking form.
I confirm that all the information I have given is correct to the best of my knowledge.
I understand that if full payment for my child’s place is not made at the time of booking the place is not
confirmed until this is received.
I understand it is my responsibility to double check the emergency contact details and medical/health details
held by the club and head office before each holiday club to ensure they are accurate.
FULL NAME
PARENT/GUARDIAN :
SIGNATURE OF
PARENT/GUARDIAN :
DATE:
This form can either be printed, completed, scanned and emailed back to our email. Or returned to
any of our 3 Club Vale settings; St Martins Junior or Infant School, Cuddington Croft School,
Danetree School or posted to
Karen Dandy, 7 The Spinney, Epsom Downs, Surrey KT18 5QX
Parents/guardians must notify Club Vale of any changes to these details immediately
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