CONTACTS & CHILD PROTECTION FORM

Name of child

Name of parent/guardian

Address

Email address

Emergency contact details

Home Phone

Work Phone

Mobile Phone

Other contacts (please name & state relationship)

What’s the best method of contact for non-urgent communications?

Email                Text Message

Is your child allowed to leave the lesson alone?

List people who will regularly collect your child from their lesson.

(Please let me know at the start of a lesson if someone not on the list is collecting your child. It would be helpful to know if there is anyone who is not allowed to collect your child – if you don’t wish to write this here please tell me in person. All information will be treated as strictly confidential.)

Does your child:

• Wear glasses?

• Have any health problems or allergies?

• Have any learning difficulties? (If yes, please tick and put any additional information in adjacent box)

Do you and your child consent to their name and/or picture being used on my website and business

Facebook page?

Please use this space for any other information you think may be

relevant.