Activity: Disability Dance September to December

Location: Wandle Recreation Centre

Date: 1st term20/09/1527/09/15 04/10/15

11/10/1518/10/15

2nd term08/11/1515/11/1522/11/15

29/11/1506/12/1513/12/15


Time: 10.30am – 11.15am

11.30 – 12.15pm

Participants First Name: ______Participants Surname: ______

Date of birth: ______Age: ______Male Female

Address: ______

School:______

Name of parent/guardian of participant: ______

Telephone: ______email: ______

Ethnic background:White Black/Black British Asian/Asian British

Chinese Mixed Other (please specify): ______

Does the participant have a recognised disability: Yes No If yes please state: Visual Learning Hearing Physical

Details: ______

Medical Health Information

Please indicate below if you or your child is affected by an illness or injury that might affect your/their sporting activity. Please note that all information given below will remain strictly confidential.

Asthma Diabetes Epilepsy Heart conditions

Details if yes to any of the above: ______

______

Is your child on any medication/s: If so what and until when? ______

______

Name of Doctor: ______Names of Doctors surgery: ______
Telephone: ______

Name of individual to be contacted in case of emergency: ______

Relationship to participant: ______

Telephone 1: ______Telephone 2: ______

Parent/ Guardian Consent

I have understood the purpose of the above information, and give my consent for my child to take part in exercise and physical activity sessions organised by Wandsworth Sports Development Team. I have completed the necessary medical details and consent that in the event of illness or accident, any necessary treatment can be administered. I understand that while the instructors and personnel will take every reasonable precaution to ensure that accidents do not happen, they cannot be held responsible for any loss, damage or injury involving, or suffered by myself or my child. I agree to abide by the policies and directives of Wandsworth Leisure and Sports Services, its staff and agents throughout the entire programme, and understand that if I do not, I may be required to leave the session. I will not be allowed to return unless agreed to by all relevant parties. I understand that there are risks involved in participating in physical activity. I will inform the instructor if my child’s medical condition changes whilst he/she is taking part in the programme.

Please note that to promote activities, official photographs may be used for official publications promoting activities. If you do not want your child’s picture to be published, please tick this box.

Signed: ______Date: ______

Please return to:

Kay Swygart

Leisure and Sport Services

Wandsworth Borough Council,

Wandsworth High Street

London, SW18 2PU