Registration CHILD’S CONFIDENTIAL PERSONAL RECORD Child's name(*) Invalid Input Child's date of birth(*) Invalid Input: please use only numbers and the following symbols - / Home address(*) Invalid Input Postcode(*) Invalid Input, Please use only letters and numbers. Mother's details First name(*) Invalid Input- Please use only letters and spaces. Last name Invalid Input Work number(*) Invalid Input Mobile number(*) Invalid Input Place of work(*) Invalid Input Father's details First name(*) Invalid Input Last name Invalid Input Work phone number(*) Invalid Input Mobile number(*) Invalid Input Father's place of work(*) Invalid Input Who to contact in an emergency(*) Invalid Input Child/Medical details Special requirements Invalid Input We must be informed of any special allergies/diet/disabilities/health problems so that your child can be looked after appropriately. If applicable please provide details below. Child's school(*) Invalid Input School tel. no.(*) Invalid Input How is your child getting to fun club(*) Invalid Input Doctor's name & address(*) Invalid Input Doctor's tel. no.(*) Invalid Input Sun cream(*) YesNo Invalid Input Do you give permission for staff to apply sun cream to your child? (Our club use Factor 30 sun cream) Can we seek treatment(*) YesNo Invalid Input May we seek emergency medical treatment for your child at hospital or at the doctors? Has your child had a Tetanus injection YesNo Invalid Input If yes, please specify Approximate date of Tetanus(*) Invalid Input Permission to be photographed(*) YesNo Invalid Input Do you give permission for your child/children to be photographed? These photos will only be shown at the Club, they will not be put on the internet. We will seek permission for special occasions. Additional info about child Invalid Input. We only accept the following special characters ,./+()" "=? Anything else the Playleader should know about your child: Allergies, dietary or medical conditions.(*) YesNo Invalid Input Please provide a photograph and more information if your child has any allergies, dietary or medical conditions. Child's photo(*) Invalid Input Please click on the "browse" button to upload a photo of your child. Allergy details(*) Invalid Input Please provide as much information as possible about your child's allergies, dietary requirements or medical conditions below. Prolicies & procedures(*) Yes Invalid Input I have read and understand the Policies, Procedures and Practices for Parents/Carers and agree to abide by them. Failure to follow these rules and regulations may result in your child losing their place with us. Signature(*) Invalid Input The person completing this form should sign in the space provided. Signators name Invalid Input Email address(*) Invalid Input This email address will be the address your registration confirmation will be sent to. Signator's relationship with child(*) ParentGuardianOther Invalid Input If 'other' please specify. State relationship if not parent or guardian(*) Invalid Input State relationship if not parent or guardian Attendance Attends After School Club at: - Hitchin Fun Club Invalid Input First time attending this scheme?(*) YesNo Invalid Input Captcha(*) Invalid Input Click the submit button to complete your registration. Submit