Registration Form for Kids Club Ely

Child’s first name: *

Child’s surname: *

D.O.B: *

Age: *

Preferred name: *

Gender: *

Male

Female

Child's school: *

Class: *

Year: *

Address: *

1 Herons Close, Ely

Post code: *

Primary contact first name: *

Surname: *

Relationship: *

Address: *

1 Herons Close, Ely

Contact number: *

Work number: *

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Na

Secondary contact first name: *

Surname: *

Relationship: *

Address: *

Daniel Everitt,
11 Meadowsweet Way Ely CB6 2SD

Contact number: *

Work number:

Email address:

Occupation:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Alternative contact no.1 name: *

Relationship: *

Mobile number: *

Other number:

Alternative contact No.2 name: *

Relationship: *

Mobile number: *

Other number:

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

Jacqueline Starkey

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.kidsclubely.co.uk:

Declaration :

I consent to my child attending Kids Club Ely Ltd. I understand that the club has policies and procedures and that there are exceptions and obligations relating to the club, myself and my child agree to abide by them. I am aware that late collection will result in a charge of £1 per minute. I understand that persistent late or non payment of fees may jeopardise my childs continued place. I confirm that the information on the form is correct and agree to notify the club of any changes. I understand the information given on the form is confidential. I am aware that Kids Club Ely may need to share information relating to my child with other people. I understand that Kids Club Ely Ltd has a duty to report suspected child abuse or neglect. I have read the above conditions for my child attending Kids Club Ely Ltd

Yes No

Full Name of Parent/Carer:

Digital Signature

Mel

Date & time:

26, Feb 2023 08:13 pm

Kids Club Ely

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service