Registration Form for Poppleton Road Out of School Club

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Child's school: *

Class/Year: *

Address: *

3 Monarch Way

Post code: *

Primary contact first name: *

Surname: *

Relationship:

Address: *

3 Monarch Way

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Usually unavailable on mobile between 8am and 4pm on days when Isla is in club. 
If urgent please ring work number and office staff will be able to get a message to me.

Secondary contact first name:

Surname:

Relationship:

Address:

3 Monarch Way

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:

Mobile number: *

Work number:

Contact No.2 name: *

Relationship:

Mobile number: *

Work number:

Does those named in the boxes above live/work in York?: This enables us to contact the closest emergency contact, in the event of an emergency. *

Yes

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.poppyroadkidsclub.co.uk:

Declaration :

I accept the terms and conditions of Poppleton Road Out of School Club

Yes No

Full Name of Parent/Carer:

Digital Signature

Ruth Butterworth

Date & time:

12, Apr 2024 05:27 am

Poppleton Road OOSC

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