Registration Form for InspirePlay Centre

Student first name: *

Student surname: *

D.O.B: *

Age:

Preferred name:

Student's gender: *

Male

Female

Prefer to self-describe

Describe Gender:

Is your child currently attending a school or nursery?:

Yes

Year:

Address:

8 Summerhill Crescent
Liverton

Post code:

Language(s) spoken:

Is English your child's first language?:

Club Registration: Please select which Club you would like to register for.

Moor Fun Wrap Around Club

Eric Mann SEN Holiday Club

Relaunch, Rotherham

Primary contact first name: *

Surname: *

Relationship: *

Email address: *

Contact number: *

Work number: *

Address: *

8 Summerhill Crescent
Liverton

Secondary contact first name: *

Surname: *

Contact number:

Work number:

Address: *

8 Summerhill Crescent
Liverton

Email address:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Are there any other contact restrictions?:

Yes

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 18 years or over):

Fasal Rashid (Grandad) 07449 028087
Nahida Faisal (Grandma) 07761 395525

Allergies, if any: *

Allergic reactions - Severity: *

Not Applicable

Very high

High

Medium

Low

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 additional needs / learning difficulties /disabilities or requires additional assistance, please specify them here.: *

ADHD

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

Likes cheese

Other Religion:

Contact details of any involved professionals: *

N/A

Proposed sessions:

SEN holiday club

Proposed dates / days:

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

Any other instructions :

Early registration is recommended. Registrations will be considered in the order in which they are received. 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.

Declaration :

I accept the terms and conditions of InspirePlay

Yes No

Full Name of Parent/Carer:

Digital Signature

Annie

Date & time:

20, May 2026 08:37 pm

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