REGISTRATION CONSENT FORM.

Because of the requirements of the Children’s Act, a separate form is required for each child

THE INFORMATION IS CONFIDENTIAL AND WILL BE KEPT AS SUCH.

Full name of child……………………………………………………………………………………….

Date of Birth…………………………………………………………………………………………….

Address……………………………………………………………………………………………………

…………………………………………………………………………………………………………….

Postcode………………………………..      Telephone number……………………………………

 Mobile …………………………………………

 School……………………………………………………………………………………………………

Age ………………..       

Emergency contact  …………………………………………..

I authorise only (name of responsible person)..........................................................................................

To collect my child OR I allow my child to return home alone. (please delete as appropriate)

 G.P name and telephone number…………………………………………………………………………

 Relevant information we should know about. (e.g. allergies, special needs etc.)………………………

…………………………………………………………………………………………………………….

In the unlikely event of illness or an accident I give my permission for any appropriate first aid to be given by a First Aider. In an emergency, and if I cannot be contacted, I give consent for my child to receive treatment by a G.P and/or hospital, including treatment under a general  anaesthetic. I understand that every effort will be made to contact me as soon as possible.

I confirm that the above details are correct to the best of my knowledge.

Signature of parent/ adult with parental responsibility……………………………………………………

Name( printed)…………………………………………………………………………………………….

  

                  PLEASE RETURN THIS FORM TO: MRS. Y. GORMLEY, 
        8 BROADWAY ROAD,  HINTON CROSS, EVESHAM, WORCS, WR11 2QS. 
...................................................................................................................................................................................
   KEEP THIS AS A REMINDER OF THE DATE