Kingdom of Flippity Flip – Registration

CHILD CONTACT DETAILS & INFORMATION

Name of Child *

First

Last

Date of Birth *

School Year *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Home Phone

Register Child 2

Add information for a 2nd child at the same address

Name of 2nd Child *

First

Last

Date of Birth of 2nd Child *

School Year of 2nd Child *

Register Child 3

Add information for a 3rd child at the same address

Name of 3rd Child *

First

Last

Date of Birth of 3rd Child *

School Year of 3rd Child *

MEDICAL INFORMATION

Please provide details of any medical conditions, disability, allergies, dietary needs and special needs

If registering more than one child please specify which child the information applies to.

Family Doctor

Doctor's Surgery

PARENT/CARER 1 INFORMATION

Name of Parent/Carer 1 *

First

Last

Contact Number for Parent/Carer 1 *

Email of Parent/Carer 1 *

Email

Confirm Email

Relationship to Child/Children of Parent/Carer 1

Different address for Parent/Carer 1

Address of parent/carer 1 is different to the child’s

Address of Parent/Carer 1

Address Line 1

City

State / Province / Region

Postal Code

ADDITIONAL PARENT/CARERS

Add Parent Carer 2

Add information for a 2nd parent/carer

PARENT/CARER 2 INFORMATION

Name of Parent/Carer 2 *

First

Last

Contact Number for Parent/Carer 2 *

Email of Parent/Carer 2

Email

Confirm Email

Relationship to Child/Children of Parent/Carer 2

Different Address for Parent/Carer 2

Address of parent/carer 2 is different to the child’s

Address of Parent/Carer 2

Address Line 1

City

State / Province / Region

Postal Code

Add Parent Carer 3

Add information for a 3rd parent/carer

PARENT/CARER 3 INFORMATION

Name of Parent/Carer 3 *

First

Last

Contact Number for Parent/Carer 3 *

Email of Parent/Carer 3

Email

Confirm Email

Relationship to Child/Children of Parent/Carer 3

Different Address for Parent/Carer 3

Address of parent/carer 3 is different to the child’s

Address of Parent/Carer 3

Address Line 1

City

State / Province / Region

Postal Code

CONSENTS

Photos Consent (Local Display or Publicity)

I consent to photos being taken of my child/children for local display or publicity.

Photos Consent (Website)

I consent to un-named photos being used on the church website.

Receive First Aid

In an emergency, if I cannot be contacted, I give permission for my child/children to receive first aid or necessary hospital treatment, including anaesthetic.

AFTER CLUB EVENT / PROMOTIONAL MATERIAL

Attend Lunch

I would like to attend the picnic lunch on Sunday at the end of the week.

Number of family members (including the child/children) who will attend the picnic lunch.

Future Activities

Please keep me informed of any other activities for children and families at Bourne Baptist

Future Events

I would like my eMail address to be added to the Bourne Baptist Church events mailing list.

DECLARATION (to be completed by a parent/carer with parental responsibility)

Consent *

I confirm that the above details are correct. I give permission for my child to take part in the normal activities of the holiday club. I also agree to immediately inform the group leaders if anything written on this form about the child changes. I understand that information provided for the child/children and for all parent/carers will be stored electronically and in paper format.

Name of Person Completing Form *

Kingdom of Flippity Flip Holiday Club Registration!

CHILD CONTACT DETAILS & INFORMATION

MEDICAL INFORMATION

PARENT/CARER 1 INFORMATION

ADDITIONAL PARENT/CARERS

PARENT/CARER 2 INFORMATION

PARENT/CARER 3 INFORMATION

CONSENTS

AFTER CLUB EVENT / PROMOTIONAL MATERIAL

DECLARATION (to be completed by a parent/carer with parental responsibility)