Registration Form for St Michaels RCP Wraparound Care Club

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Class:

Year:

Address:

120 Dale Street Chatham ME46QH

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

120 Dale Street Chatham ME46QH

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Ruth Olukoga

Secondary contact first name:

Surname:

Relationship:

Address:

120 Dale Street Chatham ME46QH

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:

Same as child

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

2 Bristol Close, Rochester ME2 2QG

Mobile number:

Work number:

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

Password for pickup- Daystar

Doctor's name:

Surgery address:

City way Rochester

Surgery phone Number:

Allergic reactions - Severity: *

Very high

High

Medium

Low

Allergies, if any:

Medical conditions, if any:

Does your child have any dietary requirements?:

Yes

Special needs:

Specific likes/dislikes:

Fussy eater

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:

none

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

no

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Secret password:

Other Religion:

First language:

English

Any other relevant information:

no

When would you like your child to start with us?:

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

Any other instructions : This form must be signed by the parent(s)/guardian(s) applying for admission of the named child and who it is assumed will be responsible for the fees. For more details, please visit our website: www.stmichaelsrcp.org:

Declaration :

I accept the terms and conditions of St Michael's Wraparound Care Cub

Yes No

Full Name of Parent/Carer:

Digital Signature

Cristina Bercus

Date & time:

09, May 2022 04:55 pm

St Michael's Wraparound Care Club

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service