Child’s first name: *

Child’s surname: *

D.O.B: *

Age: *

Preferred name:

Gender: *

Male

Female

Class:

Year: *

Address:

153 Crabtree Lane

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

153 Crabtree Lane

Contact number: *

Work number: *

Email address: *

Are there any other contact restrictions?:

Yes

Details:

Lesley Martin

Secondary contact first name: *

Surname: *

Relationship:

Address: *

153 Crabtree Lane

Contact number: *

Work number: *

Email address: *

Occupation:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Contact no.1 name: *

Relationship:

Address: *

999 high st

Mobile number: *

Work number: *

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

MartineSinnott

Doctor's name: *

Surgery address: *

Davenport House Surgery

Surgery phone Number: *

Allergens severity: *

Very high

High

Medium

Low

Allergen's Name:

Medical condition(s) if any:

Does your child have any dietary requirements?:

Yes

Special needs:

Specific likes/dislikes:

Iris is a vegetarian

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

None

Does your child have any special educational needs (SEN)?:

Yes

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

he is bilingual hence his English is yet not at fluent as other children his age

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

Iris is expected to start reception in Sept 2020

Secret password:

Other Religion:

Please read our Terms & Conditions View T&C's

Any other instructions : Please email a photograph of your child to manlandtimeoutclub@gmail.com. Registrations without photographs will not be accepted.:

Declaration :

I accept the terms and conditions of Time Out Club

Yes No

Full Name of Parent/Carer:

Digital Signature

Lesley Martin

Date & time:

19, Apr 2020 12:09 pm

Time Out Club

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

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