LITTLE MIX WORKSHOP –THURSDAY 5th APRIL 1.00pm – 4.00pm

Friendship House, Love Lane, Minster on Sea

CHILDSNAME ______DOB / / AGE_____

ADDRESS ______

______Home No:______

EMAIL ADDRESS______

PARENTS NAME ______

FAVOURITE LITTLE MIX MEMBER______

FAVOURITE LITTLE MIX SONG ______

On the day we will be painting nails, having glitter tattoos and glitter spray in our hair, if your child has any allergies to products or isn’t allowed please state here ______

______

Payment can be paid via BACS: Account No: 33055140 Sort Code:20-18-93

Please put your child’s name in the reference, via paypal through the website in the webstore (admin fee applies) or in cash with a completed form at one of my classes

NEXT OF KIN DETAILS

EMERGENCY CONTACT______RELATIONSHIP TO CHILD______

EMERGENCY CONTACT______RELATIONSHIP TO CHILD______

Is your child able to go to the toilet by themselves YES NO

MEDICAL CONDITIONS

Does your child have or ever experience the following? Please circle the relevant answer

Diabetes / YES / NO
Chest pains brought on by physical exertion / YES / NO
Childhood epilepsy / YES / NO
Dizziness or fainting / YES / NO
A bone, joint or muscular problem or arthritis / YES / NO
Asthma or other respiratory problems / YES / NO
Any sustained injuries or illnesses / YES / NO
Is your child taking any medication? / YES / NO
Has anyone in your family had a heart problem at a young age? / YES / NO
Any allergies / YES / NO
Has your child ever been in hospital? / YES / NO
If yes, please give details here:
Is there any reason not mentioned above why any type of physical activity may not be suitable for your child? / YES / NO
If yes, please give details here:
Are there any special dietary needs your child has? / YES / NO
If yes, please give details here:
  • In signing this form, I the parent/guardian of the aforementioned child, affirm that I have read this form in its entirety and have answered the questions accurately to the best of my knowledge.
  • I understand all accidents will be documented, and that I will be informed
  • I understand that if the instructor requires further information about my child’s illness or disability in order to include him/her in activities I will endeavour to make sure this information is available.
  • I understand if my child fails to behave in a manner that is polite and social, he/she may be excluded from that activity at the discretion of the instructor and will have the opportunity to rejoin the session shortly after
  • I hereby give permission for you to video or take photos my child whilst taking part in classes – this can be used on the website, social media and in the newspaper.

Signed ......