FISHERWICK PRESBYTERIAN CHURCH
HOLIDAY BIBLE CLUB 2017
REGISTRATION AND CONSENT FORM

Please use a separate form for each child.

Child's Name (required)

Date of Birth (required)

Child's Age (required)

Class your child will be entering in September 2016.

Parent/Carer's Name (required)

Your address

Postcode

Your Email (required)

Contact numbers:
Home:
Work:
Mobile:

Emergency contact names and phone numbers (if parent/carer above not available):
Name:
Phone:
Relationship to child:
OR
Name:
Phone:
Relationship to child:

Child's GP details
Name of GP:
Phone number:
GP address

Details of any known conditions, allergies etc (for example, asthma, diabetes, epilepsy) and any medication being taken:

Any other special needs, requirements or directions that would be helpful for the leaders to know about.

I give permission for photographs and video to be taken within the club for use at the club and future events:

I give permission for my child's name and details to be entered in the church database:

How did you find out about the Fisherwick Holiday Bible Club?

DECLARATION OF CONSENT

I confirm that the above details are complete and correct to the best of my knowledge.
In the unlikely event of illness or accident, I give permission for appropriate first aid to be given.
In an emergency, and if I cannot be contacted, I am willing for my child to be given hospital treatment, including anaesthetic if necessary.
I understand that every effort will be made to contact me as soon as possible.

Your Name: (Parent/Carer)

Your email address:


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