Please read the Playworks
Terms and Conditions
prior to completion of this registration form.
Name of Club
School attended
+ Class
Your Details
Surname
Home Tel
First Name
Work Tel
Address 1
Mobile Tel
Address 2
Address 3
Email
Post Code
Child Details
Surname
Date of Birth
(dd/mm/yy)
First Name
Name know by
Childs Doctor
Address 1
Surgery Address
Address 2
Address 3
Post Code
Surgery Tel No.
Male/Female
Male
Female
First Language
Religion
Does your child have any medical conditions / Allergies?
Yes
No
Does your child self administer Asthma medication?
Yes
No
Does your child have any specific dietary needs or food allergies?
Yes
No
If you have answered YES to any of the above questions, then please give details below:
Do you give consent for emergency medical treatment?
Yes
No
On which days will your child be attending the club?
MON
TUES
WED
THURS
FRI
After School
Wrap
Holiday
Breakfast
What date would you like your child to start at the club
dd/mm/yy
Please provide details of friends or family members who are authorised to collect the child who can be contacted in an emergency.
Name
Tel Home
Tel Work
Tel Mobile
I confirm that i have read the Playworks Childcare Terms and Conditions
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