Registration Form for Basecamp CIC

Student first name: *

Student surname: *

Preferred name:

Child’s Current School:

D.O.B: *

Age:

Student's gender: *

Male

Female

Prefer to self-describe

Class Name:

Address:

7 Calvert Road, London SE10 0DH

Year:

Post code:

Language(s) spoken:

Is English your child's first language?:

Primary contact first name: *

Surname: *

Relationship:

Address: *

7 Calvert Road, London SE10 0DH

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

No

Secondary contact first name:

Surname:

Relationship:

Address:

7 Calvert Road, London SE10 0DH

Contact number:

Work number:

Email address:

Occupation:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Address:

23 tunnel avenue

Relationship:

Contact no.1 name:

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

23 tunnel avenue SE10 0SF

Mobile number:

Work number:

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

Ghita Houcham
23 tunnel avenue SE10 0SF

Allergic reactions - Severity: *

Not Applicable

Very high

High

Medium

Low

Allergies, if any:

Medical conditions, if any:

Does your child have any dietary requirements?:

Yes

Special needs:

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:

Autism

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

Has speech therapist.

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

Any other instructions :

This form must be signed by the parent(s)/ guardian(s) with parental responsibility; applying for admission of the named child and who it is assumed will be responsible for the fees.

Please ensure you fill in all the important information about your child so that we can be fully aware of all their needs, likes/dislikes and conditions.

Declaration :

I accept the terms and conditions of Basecamp CIC

Yes No

Full Name of Parent/Carer:

Digital Signature

Linh

Date & time:

24, Nov 2023 12:10 pm

Basecamp Bridge

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