Explorer Registration Form
Registration form for 2020-21
Email address *
Name of child *
Date of Birth *
Sex *
Year Group for 2020-21 *
Emergency contact Name - Primary *
Emergency Contact Telephone Number - Primary - Daytime *
Emergency Contact Telephone Number - Primary - Mobile *
Address of Primary Emergency Contact *
Primary contact - Relationship to child attending the club *
Emergency - Secondary contact name *
Emergency - Second contact telephone number - daytime *
Emergency - second contact telephone number - Mobile *
Relationship of second contact to child attending club *
Address of Second Emergency Contact *
Todays Date - Date of completing the form *
Add details of other people other than the primary and secondary you would allow to collect (No more than 3 please) *
Please ensure that you understand the terms and conditions of the club and have read the policy and additional information available on the school website. *
I agree to dojo photos of my child and work being shared as part of the ongoing Explorer story *
I agree to Photographs and work of my child to go onto the explorer school website site and in newsletters to parents and pupils of the school. *
Tick to say you understand that any member of Southfields School and the Explorer club who has a concern relating to safety, welfare, child protection has a duty of care to report this to Safeguarding leaders within the school *
Medical Information - Doctors Name *
Surgery Address *
Surgery telephone number *
I give permission to use a plaster or dressing on a minor cut *
I can confirm that the named child has received all relevant vaccines. *
Medical conditions - please explain here if your child has any medical conditions
Dietary conditions - please explain here if your child has any dietary conditions
Allergies - Please explain here if your child has any allergies
Please provide any information about special requirements E.G Special Needs, Behaviour difficulties, Religious requests or anything you would like to bring our attention to.
Emergency Medical Consent - I tick the box to give consent for medical treatment/first aid which is urgently required - for instance hospital treatment if a parent can not be reached. Or within school if there is an emergency. *
I allow my child to take part in activities within the club *
I would like you to consider these things when taking part in activities - additional information you would like to add as a parent/carer
Please tick to say you understand that places must be booked by the Wednesday for the following week. And that should you book after this time your place will be taken off as registers will have been completed. *
I give permission to watch a PG film *
I understand the importance of and will make sure I drop off at 8.00 - 8.10 in the morning *
I understand the importance of picking up at 5pm *
Tick the box to agree to pay a late pick up payment fee if additional costs are incurred by the school due to staffing for late pick up. *
Other siblings I am going to register with the club and year groups that may slightly effect drop off and pick up times in this school due to moving around the building I would like you to consider.
Please tick the box below to act as an online signature to agree that you have read the Explorer Terms and conditions and parent handbook (Available on the website) by ticking this box you are allowing the information in this form to be used by the club in regards to contacts and provision for your child. As per data Protection Act 1998. *
Name of Adult completing the form *
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