|
Kidz Klub Strathearn - Registration & Consent Form All parts to be completed by Parent/Carer Please use block capitals
Part 1: CHILDS
DETAILS (Separate form for each child
attending) First Name Surname House name/number: Street Town Postcode: Date of Birth: Mother/Partner Name: Your relationship to child listed above: Mothers Home Phone No: Mothers Mobile Phone No: Father/Partner Name: Your relationship to child listed above: Fathers Home Phone No: Fathers Mobile Phone No: Alternative Contact Name: Alternative Contact Relationship: Alternative Contact Home No: Alternative Contact 2nd Alternative Contact Name: 2nd Alternative Contact Relationship: 2nd Alternative Contact Home No: 2nd Alternative Contact Allergies/Special Requirements: Family GP Name: Doctors phone No: Doctor practice address:
Part 2: STATEMENT OF CONSENT I consent for my above named
child to attend/participate in all Kidz Klub Strathearn activities,
whether arriving by the dedicated pickup/drop off Kidz
Klub bus, or on foot (accompanied or unaccompanied
by an adult - at the registration desk). And that they will return the way
they arrived (unless by prior arrangement on arrival). I understand that Kidz Klub Strathearn
may take video clips/photographs as an integral part of multi-media
activities and these may also be used for information/promotion (excluding
the internet). I understand that this is a Christian based activity (see over
for more details). I also give consent for Kidz Klub Workers to administer first aid that may be
necessary to my child in the event of an injury and for my child to receive
any necessary medical/hospital/dental treatment including an anaesthetic.
I recognise that the above named
child is my responsibility, from when they enter the building, and then
from when they leave the Kidz Klub building. Or, if a dedicated Kidz
Klub bus picks up on my route, the above named
child is my responsibility until they board, and from when they step off the
bus on the return journey. Please note: Kidz Klub understands that some children are allowed to walk
to and from the bus or the Kidz Klub
venue on their own. However, where children are dropped off and collected, it
is YOUR responsibility to collect or make suitable alternative arrangements.
Procedure for children who are not collected after Kidz Klub as expected. Where
children are registered to be collected at the end of Kidz
Klub and they are not collected; in an attempt to
arrange for collection and care of the child, Kidz Klub will first phone the parents/carers and if no reply,
the 1st alternative contact, then the 2nd alternative. If we are unable to
make contact with any of the above to make satisfactory arrangements for the
childs collection, Kidz Klub
reserve the right to contact the Perth & Kinross - Duty Child Care Team.
Parent/Carers Name Signed Date
Part 3: ADDITIONAL STATEMENT OF CONSENT In
addition, by signing below, you may also give Kidz Klub permission to let your child suggest alternatives to
arrange collection such as phone a friends parents (possibly whose child also
attend Kidz Klub), a
neighbour, or nearby relative so that they assist with the safe keeping of
your child.
Signed Signature indicates parental responsibility. From time to time information may be required to be updated. 23/5/08
Kidz Klub Strathearn, c/o Euan Brander, 07734 298 294. Info@KidzKlubStrathearn.org KidzKlubStrathearn.org |