Registration Form for Country Kids Stay & Play

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Child's school:

Class:

Year:

Address:

18 Woodnewton Road, Nassington

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

6 Parkway, Nassington,PeterboroughPE8 6QE

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Tim Mason Father - 07793110367

Secondary contact first name:

Surname:

Relationship:

Address:

Parkway

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:

Wittering

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

19 Fenn close

Mobile number:

Work 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:

Usually dislikes meat.

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:

Damien can become angry and dysregulated,  if he does he needs firm vote Kind reassurance and about 10mins to calm down. He does respond to that is not acceptable behaviour and can be redirected or distracted.

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

Damien needs reminding to go to toilet as he sometimes forgets if he is having fun.

Secret password:

Other Religion:

First language:

English

Any other relevant information:

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.insert-your-website-address-here.com.:

Declaration :

I accept the terms and conditions of [Club Name]

Yes No

Full Name of Parent/Carer:

Digital Signature

Hannah

Date & time:

24, Apr 2023 08:16 pm

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