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Child's Full Name
(Required)
First
Middle
Last
Preferred Name
(Required)
First
Date of Birth
(Required)
MM slash DD slash YYYY
Shoe Size (Roller Blading)
Primary Carer
(Required)
First
Last
Contact Number
(Required)
Email
Address
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
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Mongolia
Montenegro
Montserrat
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Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
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Norway
Oman
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Palestine, State of
Panama
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Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
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Saudi Arabia
Senegal
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Slovakia
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Somalia
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South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
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Uruguay
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Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
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Country
Please let us know how you heard about our Holiday Club
Please tick which days you would like your child to attend.
Monday 24 July (Morning)
Monday 24 July (Afternoon)
Monday 24 July (All Day)
Tuesday 25 July (Morning)
Tuesday 25 July (Afternoon)
Tuesday 25 July (All Day)
Wednesday 26 July (Morning)
Wednesday 26 July (Afternoon)
Wednesday 26 July (All Day)
Thursday 27 July (Morning)
Thursday 27 July (Afternoon)
Thursday 27 July (All Day)
Friday 28 July (Morning)
Friday 28 July (Afternoon)
Friday 28 July (All Day)
Medical Declaration
Doctor's Name
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
Last
Address
Street Address
City
ZIP / Postal Code
Phone
Has your child ever had any of the following?
Asthma
Diabetes
Fainting
Migraine
Heart Condition
Fits/Blackouts
Severe Headaches
Travel sickness
If yes to any of the above please list medication and dosage
Does your child have visual/hearing problems?
Yes
No
If yes, please specify
Does your child have any special educational needs/learning difficulties?
Yes
No
If yes, please specify
Does your child have any special dietary requirements or food allergies?
Yes
No
If yes, please specify
Is there any other information about your child you feel we should know? (providing as much information as possible will help us to plan the best experiences for your child)
Permissions/Consent
I consent to face paints being applied on my child
Yes
No
I consent to temporary tattoos being applied to my child
Yes
No
I consent to sun cream being applied on my child if they are unable to themselves. (You must provide your own sun cream)
Yes
No
I give permission for my child to receive emergency treatment when necessary by a trained First Aider.
Yes
No
I give permission for the use of plasters to be used should a First Aider feel they are required.
Yes
No
I give permission for my child, if necessary, to be taken to the Accident & Emergency department in an ambulance. (A member of staff would always accompany your child in this situation)
Yes
No
I give permission for my/our child to be photographed for sole use by the school for marketing purposes.
Yes
No
I consent to my child being taken off the school site to participate in activities and trips.
Yes
No
I consent to my/our child being carried by public transport or school transport driven in a responsible manner by an adult who is suitably qualified and insured.
Yes
No
Other Persons authorised to Collect Child/ren
Name
First
Last
Relationship to child
Name
First
Last
Relationship to child
Name
First
Last
Relationship to child
For safeguarding reasons please provide us with a password for use when collecting your child
Emergency Contacts
Contact 1 - Name
First
Last
Relationship to child
Phone
Contact 2 - Name
First
Last
Relationship to child
Phone
Consent
I/we confirm that the above information is correct and that I/we will provide any necessary medication for our child with appropriate instructions.
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Our School
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