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Child’s first name: *

Child’s surname: *

D.O.B: *

Child's gender: * Male Female

Child's school:

Class:

Address:

Post code:

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Primary contact first name: *

Surname: *

Relationship:

Address: *

Contact number: *

Work number:

Email address: *

Are there any other contact restrictions?: Yes No

Details:

Secondary contact first name:

Surname:

Relationship:

Address:

Contact number:

Work number:

Email address:

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Details must be different from previous section –‘Parental Responsibility’

Contact no.1 name:

Relationship:

Address:

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

Mobile number:

Work number:

I, hereby consent and grant permission to the following persons to collect my child (Must be 18 years or over):

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Doctor's name:

Surgery address:

Surgery phone Number:

Allergens severity: * NA Very high High Medium Low

Allergen's Name:

Medical condition(s) if any:

Does your child have any dietary requirements?: Yes No

Special needs:

Specific likes/dislikes:

Medication (Please list any medication your child takes regularly and the dosage):

Does your child have any special educational needs (SEN)?: Yes No

If your child has any learning difficulties/disabilities or requires additional assistance, please list them here:

Any other relevant information we may need to be aware of ?:

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Religion:

Christian Muslim Buddhist Jewish Sikh Hindu None Prefer not to say Others - please state

Other Religion:

Secret password:

First language:

Any other relevant information:

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Consent for using images & videos of child:

From time to time we may take photographs of the children, we may use these images on our website or printed publicity. We may also make video or DVD recordings for use within the club or for monitoring purposes. Photographs or videos may also be taken by representatives from the media or local newspaper. To ensure we comply with the Data Protection Act 1998, we need your permission before we can photograph or make any recordings of your child:

I agree that my child can be photograhped or videoed for the sole purpose of sharing their activity and daily updates with me:

Yes No

I agree that my child can be included in photos published on social media:

Yes No

I agree that my child can be videoed for social media sites:

Yes No

Consent for medical advice or treatment:

I give consent to seek any necessary medical advice or treatment in the future:

Yes No

I give permission to apply plasters if needed:

Yes No

I agree that my child can be given first aid if required:

Yes No

I authorise the centre to allow the emergency contacts to pick up my child if I/the named guardians cannot be reached:

Yes No

Consent for outings:

I give permission for my child to take part in local outings. for example, trip to local museum or local park:

Yes No

I give permission to apply sun cream as necessary. Where required, I will provide sun hat, wellies or boots during hot/wet weather conditions:

Yes No

Bicycling Consent - I permit my child to ride his/ her bike to school. I will ensure that my child uses a helmet and that his/ her bike is equipped with a light:

Yes No

I agree that my child can watch a PG film:

Yes No

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Please read our Terms & Conditions

Declaration

I accept the terms and conditions of [Centre Name] Yes No

Full Name of Parent/Carer:

Digital Signature

Date & time:

07, Jun 2021 01:12 pm

St Margaret's Infant School

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