Consent Form for Leaving After School Club and Holiday Playscheme Unaccompanied
Please read the statement below.

At the end of the document please supply us with any required information.

You must complete all required sections to submit this form. YOU CAN NOT SAVE AND RETURN.
Email address *
Signature
The person signing this form must be the same person named on the registration form.

Once the child has left our building at a previously agreed time, the responsibility for the welfare of the child falls to the appropriate parent/carer.

The most senior member of staff will sign your child out on that day. We strongly advocate that a responsible adult or older sibling is at home when the child returns.
Child Name *
Parent/Carer *
Time your child will be leaving ASC or Holiday Playscheme.
What date this will start from and when it will end?
MM
/
DD
/
YYYY
Consent
I hereby give permission for my child to leave club and walk home unaccompanied.
Signature *
Date of signature *
MM
/
DD
/
YYYY
Submit
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