Child Registration Form Childs name DOB Age Parent

Child Registration Form Child’s name: _______________________DOB: ______ Age: ______ Parent/ carer Title: _______ Name: _____________ Surname: ___________ Address: ______________________________________Postcode: ________ Please provide at least two contact numbers Mobile number: _________ Home: ___________ Work: ___________ Course/ workshop attending: After school club [ ] School holiday club [ ] Breakfast club [ ] Allergies: Does your child have any known allergies (food or otherwise)? Yes [ ] No [ ] (Please note we work with nuts and other food allergens in our classes and therefore our classes may not be Allergy suitable for some allergy. Symptoms sufferers). Please name allergen, symptoms and a outline management/ Management/ treatment plan). Please continue overleaf if more space required. Medical conditions: Does your child have any known medical conditions? Yes [ ] No [ ] Condition Symptoms Management/ treatment plan). (Please provide name of condition as well as symptoms and outline a management/ treatment Please continue overleaf if more space required. Does your child have any specific learning difficulties (e. g. dyslexia, ADHD) Yes [ Please state which: ] No [ ]