St. James Summer Holiday Club Registration Form

St. James Summer Holiday Club Registration Form

For Primary school children aged 5-11

Tuesday 25th – Friday 28th July, 2017 (10.00am-12.30pm)

(One form can be completed per family)

To book your place/s please complete the form below and return with payment to your children’s club leader or to the St. James Church office. Places are limited and must be booked in advance. Thank you.

Child’s full name ______M / F D.O.B ______School Year in Sept ______

Child’s full name ______M / F D.O.B ______School Year in Sept ______

Child’s full name ______M / F D.O.B ______School Year in Sept ______

Address of child/ren______

Email address ______

Emergency contact names and numbers______

______

Doctor’s name and telephone number ______

Please give details below of any special needs, allergies, medical conditions or concerns:

______

______

Can your child(ren) have a drink and snack? YES / NO

Can your child(ren) travel home unaccompanied? YES / NO

Please list the names of ALL adults (including parents) who may collect your child(ren) each day:

Name(s) ______

(Please inform us on the day of any changes to this.)

Where did you hear about this club? ______

I confirm that the above details are correct and complete to the best of my knowledge. I will inform leaders if anything changes before the start of each day at the holiday club. In the unlikely event of illness or accident I give permission for any necessary medical treatment to be given by the nominated first-aider. In an emergency, if I cannot be contacted, I am willing for my child(ren) to receive hospital treatment, including anaesthetic if necessary. I understand every effort will be made to contact me as soon as possible.

I give permission for my details to be held on the Church Holiday Club database.

I give permission for photos/video including my child(ren) to be taken and used by the church. I understand that my child(ren) will not be named and no personal information will be displayed.

I include payment of ______(£2.50 per child per day please)

Parent / Guardian’s signature ______Date______

Parent / Guardian’s full name (Please PRINT) ______

St. James Church, 236 Mitcham Lane, Streatham. SW16 6NT Tel: 020 8677 3947 Email: