Name of Child:*
Gender:*
M
F
Child's Date of Birth:*
Primary Class in August 2017:*
Parent/ Guardian's Name and Address:*
Telephone Number:*
Parent's Mobile Number:
Parent/Guardian's email address:*
Emergency Contact Name and Address:*
Emergency Contact Telephone Number:*
Child's GP's Name, Address and Telephone Number:*
Any known allergies or conditions:*
I confirm that the above details are complete and correct to the best of my knowledge:*
Yes
No
In the event of illness or accident I give permission for appropriate first aid to be given by the nominated first-aider. In an emergency and if I cannot be contacted I am willing for my child to be given hospital treatment including anaesthetic:*
Yes, I give permission
No, I do not give permission
I give permission for my details and those of my child/children to be entered in the church database:*
Yes, I give permission
No, I do not give permission
I give permission for my child/children's photographs to be used in Greenbank online and printed publications:*
Yes, I give permission
No, I do not give permission
How did you hear about Greenbank Holiday Club?:
Advert in local magazine
Flyer distributed with Greenbank Easter card
From the Greenbank Leaflet
Flyer brought home from school
From an organisation that meets at Greenbank
By word of mouth
Other
Please enter the verification number on the right:*
six five five seven seven
* Required Fields