Registration Form for Club Spraoi Brooklodge

Student first name: *

Student surname: *

D.O.B: *

Age:

Preferred name:

Student's gender: *

Male

Female

Prefer to self-describe

Child’s Current School:

Class Name:

Address:

Apart. 3 26 Commons Road 
Blackpool

Post code:

Language(s) spoken:

Is English your child's first language?:

Primary contact first name: *

Surname: *

Relationship:

Address: *

Apart. 3 26 Commons Road
Blackpool

Contact number: *

Work number:

Email address: *

Are there any other contact restrictions?:

Yes

Details:

Small feeding disorder

Secondary contact first name:

Surname:

Relationship:

Address:

Brookhill, Glanmire, Co Cork, T45 YX21, Ireland

Contact number:

Work number:

Email address:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Contact no.1 name:

Relationship:

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Mobile number:

Work number:

I, hereby consent and grant permission to the following persons to collect my child (Must be 16 years or over):

Hevertton
Natalia

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:

No

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

He can be very hyper and also very sensitive to loud noise

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Name of class teacher:

Other Religion:

Proposed year/group:

Primary

Proposed date of entry:

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

Any other instructions :

I acknowledge that Club Spraoi are providing these services as an Independent contractor and on behalf of the board of management of the school by the trustees of the school and I understand and confirm that it has been made clear to me that no liability whatsoever will attach to or be accepted by the board of management of the said school or the trustees of the school for any neglect, action, default whatsoever of the said independent contractor his/her servant, agents and invites arising in any way out of or connected with this activity.

Declaration :

I accept the terms and conditions of Club Spraoi Brooklodge

Yes No

Full Name of Parent/Carer:

Digital Signature

Eva

Date & time:

04, Feb 2025 04:54 am

Club Spraoi Brooklodge

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