CG BOX-KIDS PARQ

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CG BOX-KIDS PARQ

Child's Name *

Parent/ Guardian Name *

Address Line 1 *

Address Line 2

City *

Postcode *

Child's Date of Birth *

YYYY

Child's Age *

Emergency Contact *

Name

Emergency Contact Number *

GP Surgery Address Line 1 *

Address Line 1

GP Surgery Address Line 2

Address Line 2

GP Surgery City *

City

GP Surgery Postcode *

Postcode

GP Telephone Number *

Does your child have or have they ever experienced any of the following (please higlight): High or Low Blood Pressure *

Yes

Elevated blood cholesterol *

Yes

Diabetes *

Yes

Chest pains brought on by physical exertion *

Yes

Epilepsy? *

Yes

Dizziness or fainting? *

Yes

Any bone, joint or muscular problems with arthritis? *

Yes

Asthma or respiratory Problems? *

Yes

Any sustained injuries or illness? *

Yes

Any allergies? *

Yes

Other:

Is your child taking any medication? *

Yes

Other:

Is there any reason not mentioned above why any type or physical activity may not be suitable for your child *

If you have answered ‘YES’ to any of the above questions, please give full details below and speak to a CG Box-Kids instructor

I give permission for my child’s photo to be taken and used on social media to promote CG Boxkid classes *

Yes

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Required

Consent *

I Consent to the terms outlined in this form

Required

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