Brunswick Membership Form
Please complete clearly and in full
Email address *
Child's first name: *
Child's surname: *
Child's date of birth: *
Child's age: *
Gender: *
School attending:
School year:
Home address (line 1): *
Home address (line 2):
Postcode: *
Parent / Carer 1 - Full Name: *
Relationship to child: *
Email address: *
Mobile no: *
Home no:
Parent / Carer 2 - Full name:
Relationship to child:
E-mail address:
Mobile no:
Home no:
Child's mobile no:
If we are unable to contact either parent/carer, please provide the name and telephone number of someone we can contact in an emergency.
Emergency contact (name & number):
Ethnic group of child: *
Does your child suffer from any ailments or disabilities, eg diabetes, epilepsy, asthma? *
Does your child take regular medication or receive any medical treatment at present? *
Is your child allergic to anything, eg any particular drugs, food, insects? *
If the answer to any of these questions is yes, please give details:
Please give details of any further information we would need to know about your child that has not been covered, eg special needs, court orders, challenging behaviour, etc:
Are you willing for your child to have their photograph taken during activities and for these to be used for Brunswick or any other related publicity? *
Parental consent details: I give permission for my child to become a member of The Brunswick Club and agree to his/her participation in all activities. I am aware some activities will involve travelling by minibus or public transport and give my permission for this. I acknowledge the need for responsible behaviour on his/her part and understand The Brunswick Club reserves the right to exclude my child temporarily or permanently, if it is considered that his/her behaviour is inappropriate or a danger to others attending the Club. I also understand by signing this form that, in the event of an accident or emergency, I agree to my son/daughter receiving medical treatment,including anaesthetic, as considered necessary by the medical authorities present. I am also authorising the Leaders in Charge to give consent on my behalf to hospital authorities. I have filled out the medical information details above correctly and to the best of my knowledge. *
Data Protection: I understand that by completing this form, the details I have provided above will be taken, stored, and processed by The Brunswick Club in order to: a) provide services and carry out administration in relation to my child’s membership; b) communicate with me about services and my child’s membership (you can opt out of this at any time by contacting us); and c) if necessary for the delivery of services, provide information about my child’s membership to other relevant agencies, e.g. delivery partners, funders, or the Local Authority. Where there is a need to protect or support a young person, I understand The Brunswick Club may also share personal information with relevant agencies as required by law. (For further information about how we process your personal information, who we may share it with, and your rights, please read our Data Protection Policy, which can be found on our website or obtained on request from our office.) *
Signed (name): *
Relationship to child: *
Date: *
A copy of your responses will be emailed to the address you provided.
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