Wednesday Sign up for your place for Summer 1

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Consent and Child information form

Chillax 4 Kids aims to provide a safe and enjoyable experience for
every child or young person.
To help us do this, please note the following important information.
• All questions on the consent form must be completed and signed by the parent
or carer before any child takes part.
• Parents and carers must ensure they notify us of any changes to the
information given on the form.
• Parents and carers must make arrangements for children to be brought to and
from the activity safely and on time. If a parent or carer is not able to collect
their child, they need to let us know in advance who will be doing so.
• We cannot take responsibility for any damaged clothing and/or personal items
during the activity.
• Parents and carers should ensure children have sufficient water, food, clothing,
sun lotion and medication (where appropriate) for the duration of the activity.

Email *

Childs Name *

Address *

Telephone number *

Date of birth *

YYYY

Parent/carers name *

Address *

Telephone number *

Emergency Name and Telephone number *

Child’s medical details and allergies. Do we need to know about any medical conditions or allergies? (If yes, pleaseprovide details of the condition(s) and any medication needed). *

Are there any activities that your child cannot participate in? *

Is there anything else you think we should know? *

Parent/Carer Agree to *

My child taking part in the stated activity

Chillax 4 Kids keeping a record of this form for Health and Safety Reason

Any medical treatment that my child may need to be given in an emergency

my child being filmed or photographed during the activity

Required

Parent/Carer Agree to the named child being filmed or photographed during the activity, with the possibilitythat these photographs/media recordings may be used for publications ormarketing publicity. Chillax 4 Kids will take all steps to ensurethese images are used solely for the purposes for which they are intended.) *

Agree

Disagree

Required

I understand that my child needs to follow the behaviour code and any safety rules so that Chillax 4 Kids can keep them and other children safe. *

Agree

Disagree

Required

I understand to pay the sum of £30 at the start of each 5 week block booking and a refund will not be given if my child is unable to attend. Payment details will be sent in an email to confirm a place. *

yes

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