Wickwar Out of School Club Registration Form 2016

Transcription

1 Registration Form 2016 All children who attend Wickwar Out of School Club must be registered with the club The information received will be treated in the strictest confidence Child s full name: D.O.B. Age: School attending: Class/teacher: Child s permanent address: address: Religion: Parent/Carer name(s): Daytime telephone numbers: Home: Mobile: Ethnicity (please tick) White British Irish Traveller of Irish Heritage Gypsy/Roma Any other white background Any other ethnic background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Mixed (white & Black Caribbean) Caribbean African Any other background Chinese Mixed (White & Black Caribbean) White & Black African White & Asian Any other mixed background Please indicate your CURRENT regular session bookings below. (Yes = currently attends session, blank = does not currently attend session) AM PM MON TUES WED THUR FRI Please indicate your preferred regular session choices for SEPT 2016 below. (Yes = required, blank = not required) AM PM MON TUES WED THUR FRI Please give 4 names and telephone numbers of people who can be contacted in an emergency and have permission to collect your child: Name: Relationship to child: Mobile telephone no: Home telephone no:

2 Person(s) NEVER to collect your child: (staff can only enforce this if there is a court order in place): Name: Relationship to child: Please give us the following medical information: Doctors name and address: Doctors telephone number: Date of last tetanus injection: Dietary requirements: Allergies: Health: Other: Please tick the relevant box so we know we have/have not your consent in the following: I consent to my child receiving medical treatment in the case of an emergency I authorise the staff of the club to sign any written form of consent required by the health authorities, if a delay in getting my signature is considered by doctors to endanger my child s health I consent to my child taking part in hand/face painting I consent to my child being photographed for the club s portfolio and for marketing/advertising purposes I consent to my child going off site for a walk/picnic during the holidays Yes No I agree to abide by the policies and procedures of the club. Yes No Parent/carers full name: Parent/carers signature: Date:

3 Allergy/Care Management Plan Child s name: Address: Date of birth: Doctor s name: Doctor s address: Allergy Plan Allergy to / triggered by? Reactions/symptons include: Please indicate what constitutes an emergency situation for your child. (That is when something other than normal care will be required.) Treatment: Medicine form attached? Yes No (tick as appropriate) Care Plan for Medical Condition Describe the Child s Medical Condition (e.g. Asthma/Eczema/ASD) and the care required: What medication will your son/daughter bring to Club? Please detail normal care requirements Please indicate what constitutes an emergency situation for your child. (That is when something other than normal care will be required.)

4 How many staff are needed? If more than one please say why. What are the child s preferred means of communication e.g. verbal, visual Is any additional equipment needed? Medicine form attached? Yes No (tick as appropriate) Parent s name: Contact details: Add here any other relevant information: This medical plan was agreed between Wickwar Out of School Club and name of parent / carer date name of staff member date

5 Permission to administer medicine form Child s name: Date of birth: Child s address: Parent s contact no: Doctor s name: Telephone no: Address of surgery: Reason for medicine: (* if more than 2 medicines to be administered by staff, please complete an additional form) Name of medicine: Storage requirements: Dosage: Times to be administered: Reason for medicine: Name of medicine: Storage requirements: Dosage: Times to be administered: I give permission for medicine to be given to my child in accordance with the details above. Parent s signature: Parent s name: Date: Staff at WOOSC will only be permitted to administer medication to your child if you complete and return this form. Under no circumstances will members of staff administer medication against the will of a child. Note that we can only administer medication containing aspirin if prescribed by a doctor. If you have any concerns or questions, please contact the WOOSC manager.