SUMMER SCHEME REGISTRATION FORM 2017

VENUE

SCHEME DATES – please circle which week(s) you require:

WEEK 1(24-28 JUL) WEEK 2(31 JUL-4 AUG) WEEK 3(7 AUG-11AUG)

Please note completion of registration formdoes not guarantee a child’s place as places are allocated on a first come first served basis.

COST: £25/WK per child, CONCESSION: £12.50CONDITIONS APPLY, SEE INFORMATION BOOKLET

We welcome applications for children of all abilities

Unfortunately, we cannot offer specialist support for individual children.

However, where appropriate, we will make reasonable adjustments, in consultation with parents/guardians.

PLEASE COMPLETE ONE FORM PER CHILD.

CHILD’S DETAILS

Name:
Address:
Town:
Postcode:
Date of Birth:

PARENT/GUARDIAN DETAILS

Name:
Address:
Town: / Postcode:
Phone Number: / Mobile:
Relationship to Child: / (e.g. Mother, Father, legal Guardian)

In case of an emergency, and in the absence of parent/guardian, please give details of 2 persons for contact: (DIFFERENT CONTACT FROM ABOVE, LOCAL AND CONTACTABLE DURING SCHEME HOURS)

Name: / Name:
Address: / Address:
Phone No / Phone no
Mobile No / Mobile No
Relationship to Child / Relationship to Child

CHILD’S HEALTH / OTHER DETAILS

To enable us to meet your child’s needs we ask that you put any Medical/Other Conditions on the Registration form.
Medical conditions
______
Disabilities
______
BehavioralConditions
Please state if any medication is taken in connection with these health/other conditions?
Any other circumstances we should know about?
Family Doctor : Doctor’s Phone Number:

OTHER DETAILS

Do you give permission for your child to walk home unaccompanied?YESNO(please circle)

If not, who will accompany him/her home? ______

GENERAL CONSENT

  • I give consent for my child to attend the Summer Scheme noted on this form. PLEASE TICK
  • I understand the policies and procedures outlined in the Information Booklet I have received and agree with their implementation.PLEASE TICK
  • I understand that registration details above may be shared with ANDBC’s Leisure Services Section, for the purposes of completion of monitoring returns to sponsoring Agencies/Departments. PLEASE TICK
  • I understand that photographs may be taken of children attending schemes for public relations purposes and for recording children’s activities (excluding swimming) and I give/ do not give consent that my child may be included in such photographs.(DELETE AS APPROPRIATE).
  • I understand that this is a general consent to attend all activities.PLEASE TICK
  • In the case of a medical emergency I give my consent for emergency medical treatment.PLEASE TICK

I CONFIRM THAT ALL DETAILS ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND I GIVE MY CONSENT FOR MY CHILD NAMED ABOVE TO ATTEND THE ARDS AND NORTH DOWN SUMMER SCHEME 2017. I enclose the fee of £ ______(Non transferablenon refundable – payment by CHEQUE / CASH ONLY please.)

Signed: ______Parent/Guardian Date______

Ards and North Down Borough Council values your right to personal privacy. We at all times try to be open about the reasons why we collect, hold and use your personal information. We collect information about you in order to fulfil our statutory obligations and provide you and other people with services. Some of the information we gather may be used to help us provide you with improved services and may be shared with Councils Leisure Services Department. We at all times aim to comply with the Data Protection Principles, ensuring that information is collected fairly and lawfully, is accurate, adequate, up to date and not held any longer than necessary. If your personal data needs to be used for purposes other than those mentioned, we will contact you to seek your consent. You have a right to see information held about you (with a few exceptions allowed for in the Data Protection Act 1998). If you wish to see any personal information held on you please put your request in writing, stating clearly who you are and what information you would like to see to the address below. A fee is chargeable up to £10.00 which covers the cost of gathering, copying and redacting the data.

Compliance Manager, Ards and North Down Borough Council, Town Hall, The Castle, BANGOR, BT20 4B

For Office Use Only: