Details will be held securely and in line with the Data Protection Act. Marketing Permissions: Wee Chicks will use the information you provide on this form to be in touch with you and to provide updates and marketing. Please let us know all the ways you would like to hear from us. You can change your mind at any time by contacting us at info@weechicks.com. We will treat your information with respect. For more information about our privacy practices please visit our website. By clicking below, you agree that we may process your information in accordance with these terms. *

Child’s Name: *

Date of Birth: ___/___/___ *

Age of child on entry:

Parent/Guardian name on birth certificate: *

Contact Phone number: *

Alternative Phone Number: *

Do you have parental responsibility for this child? *

We need two contacts to be held on file. Parent/Guardian name: *

Is the above names on your child's birth certificate?

Contact Phone Number: *

Alternative Phone Number:

Who is authorised to collect your child. Only people named can collect your child. They must show ID on collection of your child and be over 18 years old. Name and Password: *

Telephone number of person collecting your child if different from above: *

Name child prefers to be called:

Child’s Address: *

Does your child understand English? *

Is your Child on any medication? *

(If yes, please give details)

Is your child up to date with immunisations? *

Does your child have any allergies? *

If yes, please specify:

Doctors Information Name: *

Address: *

Telephone number: *

Does your child have any impairments?

Please give details:

Do you have any additional Cultrual and/or Religious beliefs?

Additional Comments & Information: Is there is any other information that would be helpful to our management and staff? for example behaviour triggers, dislike, being assessed, or waiting on assessment, low mood, anxiety due to Covid 19?

Has your child or anyone in your house hold had Covid 19 from pandemic?

Do you know what website to go to to check for update guidance on Covid 19? ( will send you the link!)

Parental/Guardian Consent (tick as appropriate) I/We give my/our permission to act on my/our behalf in case of emergency or accident and to take such action as may be necessary for the benefit of the child. The decision to be taken by the person in charge at the time of the emergency *

I/We agree to pay all reasonable costs/expenses which might be incurred in this event. *

I/We give my/our permission for my/our child to be photographed by staff for the purposes of displaying in the units, All photographs will be destroyed when the display is taken down.? *

I/We hereby give my/our permission for my/our child to be included in press releases issued by Wee Chicks Fitness CIC / Wee Chicks LTD

I/We give my/our permission for my/our child to be photographed by staff for the purposes of our website and social media. ?

I/We hereby give permission for my child to be given Calpol/Nurofen (delete if appropriate) when
necessary by the unit manager or assistant. *

I/We hereby given permission for hypo allergenic plasters to be used on my/our child if necessary? *

I/We hereby give my permission for staff to assist with cleaning my child in the event of a toileting
accident. *

I/ We hereby give permission for staff to apply sun cream to my child if necessary *

I/We agree to give notice to Wee Chicks Fitness CIC / Wee Chicks LTD when changing days of attendance. If your child does not turn up for a session they are book in for, the session cannot be transferred. At least 1 months notice required for change of days *

I/We give Wee Chicks permission to take my child to the Waterworks, Cavehill, Belfast Castle and Chichester Library and local walks.

I/We give Wee Chicks permission to collect my child from school and be transported in our car

I/We hereby agree to terms and conditions of payment of fees. If your child fails to attend you agree to pay the fee. *

What days would you like your child to attend? *

What school does your child attend and what time and where is the collection point that they need collected from? *

Parent/Guardian signature: By typing your name it is accepted as an electronic signature. *