Monkhouse Primary School Out of School Club Registration & Consent form

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Child’s full name *

Date of birth *

YYYY

Home address (including postcode) *

Class *

Reception

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Parent/Carer Information

Please add Parent/Carer Contact details below

Parent 1: Name, relationship to child, home telephone, work telephone & mobile telephone *

Parental Responsibility *

Yes

Parent 2: Name, relationship to child, home telephone, work telephone & mobile telephone *

Parental Responsibility

Yes

Clear selection

Please provide contact details for another person other than the parent who may pick the child up

Name, Address, telephone number & relationship to child *

Collection Security word *

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