Registration Form for Kneesall Out Of School Club

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Class:

Year:

Address:

Endeavour House
Newark Road
Wellow

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

Endeavour House, Newark Road, Wellow, NG22 0EN

Contact number: *

Work number:

Email address: *

Are there any other contact restrictions?:

Yes

Details:

None

Secondary contact first name:

Surname:

Relationship:

Address:

Endeavour House, Newark Road, Wellow, NG22 0EN

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:

Address:

Shortwood Farm
Shortwood Farm
Ompton

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

15 Stonebank, Mansfield, Notts

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:

N-A

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:

N/A

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

No

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Secret password:

Other Religion:

First language:

English

Any other relevant information:

None

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.:

Declaration :

I accept the terms and conditions of Kneesall Out Of School Club

Yes No

Full Name of Parent/Carer:

Digital Signature

Laura Yeardley

Date & time:

27, Sep 2023 02:40 pm

Kneesall Out of School Club

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