HSGA Playscheme Application Form 2018
To be held at: Rowley Lane Infants, Junior and Nursery School, Lepton, Huddersfield. HD5 0JD
Email address *
Huddersfield Support Group for Autism
Child's name *
Your answer
Sex *
Child's date of birth *
MM
/
DD
/
YYYY
Child's address *
Your answer
Parent/carer name
Your answer
Parent / carer contact number (home and mobile) *
Your answer
Alternative emergency contact (name, relationship, phone number) *
Your answer
Do you have social worker involvement? If so, please provide a name and contact number.
Your answer
Select age appropriate week *
Does your child need transport? (Charge of £6 per day, to be paid in advance)
Do you consent to your child *
Required
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