CONSENT FORM Holiday Club
PARENTAL CONSENT FORM - St Matthew's Holiday Club
Email address
CHILD'S FULL NAME
Your answer
ADDRESS
Your answer
DATE OF BIRTH
MM
/
DD
/
YYYY
SCHOOL
Your answer
SCHOOL YEAR GROUP
Your answer
While your child is in our care, it is helpful for us to know of any allergies or phobias, medical conditions or disabilities.
Are there any social or behavioural issues or anything else you would like us to know?
Your answer
Details of any medication (ensure it's clearly labelled with your child's name and hand it to one of the Holiday Club leaders)
Your answer
Details of dietary restrictions
Your answer
Family Doctor: Name, Address and Telephone
Your answer
Any other information the Holiday Club organisers should know
Your answer
PARENT / GUARDIAN DETAILS: Name
Your answer
Address (if different from above)
Your answer
Home / Mobile (provide at least 2 numbers)
Your answer
ALTERNATIVE CONTACT if Parent / Guardian is unavailable (provide at least 2 different contacts)
Contact 1: Name / Mobile Phone / Address
Your answer
Contact 2: Name / Mobile Phone / Address
Your answer
CONSENT: please tick A or B only
Required
Your answer
Please tick A or B only
Required
I AGREE TO ANY EMERGENCY TREATMENT TO BE GIVEN IF NECESSARY
Required
NB: The medical profession takes the view that a parent's consent to medical treatment cannot be delegated. Medical consent forms have no legal status and a doctor has the right to insist parental consent is given before treating a child. We have found, however, that medical staff find this type of general consent helpful.
We recognise that circumstances or information may change. If so, it is your responsibility to tell us of any changes, in writing .
I give permission for this information to be stored on a digital database:
PHOTOGRAPHS and short videos of activities including your child may be taken for promotional purposes. If you do NOT wish your child to be included please email Lynn Everett at: lynn.everett@st-matts.org.uk or phone 0118 954 7964
We operate a TEXT MESSAGING service to parents informing you of upcoming events relevant to your child (eg. Cinema Nights). If you prefer NOT to take part please email Lynn Everett at: lynn.everett@st-matts.org.uk or phone 0118 954 7964
Date
MM
/
DD
/
YYYY
Signature of parent / guardian (we will ask you to sign this form when you bring your child)
Your answer
A copy of your responses will be emailed to the address you provided.
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