Soul Connect Weekend Away 2019
Please read the covering letter before completing the form below
BOOKING DETAILS :
Delegate First Name *
Your answer
Delegate Surname *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Parent's Name *
Your answer
Parent's address (including Postcode) *
Please give the parent address relevant to the dates of that weekend. (e.g. the address we return them to in case of emergency).
Your answer
Parent's email *
Your answer
Parent's contact number *
relevant to the dates of the weekend
Your answer
Additional Contact number (and name) *
Your answer
Dietary Requirements
Do they have any food allergies? (please specify) *
If yes. Please give details.
Include any useful information including severity and level of caution needed.
Your answer
Do they have any general dietary requirements? *
Any other dietary details
Your answer
Allergies & Emergency Medication etc.
WILL THEY BE BRINGING EMERGENCY MEDICATION (such as Epi- Pen) WITH THEM? (If yes, contact us to arrange completing a separate ACTION PLAN form together). *
Details of any other allergies (e.g. penicillin, plasters) Include severity and other relevant information. (or write "NONE") : *
Your answer
Medical Conditions & Personal Medication
Details of any other relevant Medical Conditions or specific needs. (Or write "NONE").
Your answer
Details of any medicines they will have with them (e.g. Inhalers, anti-biotics, insulin). Include additional information useful to leaders - (or write "NONE") : *
Your answer
Are they competent self-medicating? *
if no, give details below
Any additional relevant medical information
Your answer
In the event of minor ailments (e.g. headache, period pains, hayfever, wasp sting) I am happy for my child to be given the relevant child/adult doses of ‘over the counter medication’ (such as calpol, Ibuprofen, paracetemol, piriton ). (Obviously if conditions persist or there is any apparent cause for concern medical advice will be sought and you will be contacted). *
GP DETAILS : Name, Surgery, phone number *
Your answer
I give permission for my child to attend this event and confirm I have read the weekend terms and conditions *
Required
PAYMENT DETAILS
Details on how to pay for this weekend will appear after you click SUBMIT.
Please note : without payment your child's place is not confirmed.
If booking more than one delegate, a total payment can be made after completing all the separate forms.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service