Registration Form

Child’s Details Date of Registration:

First name: / Surname: / Date of Birth:
Age:
(*5 year olds must be in year 1) / School attended: / First Language:

Parent/Guardian details

Title: / First name: / Surname / Title: / First name: / Surname
Home address: / Home address (if different):
Does this child normally live at this address? Yes / No / Does this child normally live at this address? Yes / No
Work address: / Work address:
Home number: / Mobile number: / Work number: / Home number: / Mobile number: / Work number:
Email address: / Email address:
Does this person have parental responsibility? Yes / No / Does this person have parental responsibility? Yes / No
Does anyone else have parental responsibility for this child? Yes / No (If yes, please provide details on separate sheet.)

Emergency Contact Details (please provide details of two people we can contact if we are unable to get hold of you)

Name: / Telephone number: / Mobile number:
Address: / Relationship to the child:
Name: / Telephone number: / Mobile number:
Address: / Relationship to the child:

Child’s Doctor

Name of Doctor:
Address: / Telephone:

About your child

Please detail any additional/special needs your child has: (please provide full details)
Please detail any dietary requirements / food allergies for your child: (please provide full details)
Which activity programme would your child be best suited to? (Please Circle)
Sports based Creative Arts based A mixture of Sports and Creative Arts
CONSTENT / I DO / I DO NOT
PERMISSION FOR EMERGENCY TREATMENT
I give permission for the Manager / Supervisor of SMASH Activity club Ltd to obtain any
medical treatment or assistance that may be necessary in the case of an emergency for
my son/daughter (named of this form).
PERMISSION TO ADMINISTER PRESCRIBED MEDICATION
I give permission for a First Aider to administer medication prescribed by a doctor.
A written record will be kept. An additional form will need to be completed.
PERMISSION TO USE PLASTERS
I give permission for the first aid trained staff of SMASH Activity Club Ltd to apply plaster(s)
to my child if necessary. By agreeing to this you are confirming that your child is NOT allergic
to plasters
PERMISSION TO USE FACE PAINT
I give permission for staff from SMASH Activity Club Ltd to use child friendly face paints.
PERMISSION TO USE PHOTOS/ COMMENTS/VIDEO ON FACEBOOK/TWITTER/etc.
I give permission for SMASH Activity Club Ltd to use photos/video & comments to
demonstrate the great activities and fun that the children experience
PERMISSION TO USE SUN CREAM
I give permission for staff from SMASH Activity Club Ltd to use child friendly sun cream
RISKY PLAY & MESSY PLAY
Play should be fun and this can involve getting messy. By playing children learn and develop as individuals, this can involve some level of rough and tumble and therefore risk. We carry out formal risk assessments and manage the risks and benefits of activities.

Signature of Parent/Carer Date:

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