Name *

First Name

Last Name

Date of Birth *

Watch out! Our website builder insists on month-day-year...

MM

DD

YYYY

Days Attending *

Monday 24th July

Tuesday 25th July

Wednesday 26th July

Thursday 27th July

Friday 28th July

Does s/he have any medical conditions or recurrent illness (e.g. asthma, hay fever, migraine, fits/faints, disability, etc.)? *

Yes

No

Is s/he taking any medicine or undergoing any treatment that needs to be continued during the event? *

Yes

No

Is s/he known to be allergic or sensitive to anything (e.g. penicillin, aspirin, other medicines, food, etc.)? *

Yes

No

Does s/he have any specific dietary requirements? *

Yes

No

Is there any other important medical information that you feel you should disclose? *

Yes

No

Name *

First Name

Last Name

Name *

First Name

Last Name

Do you give permission for photos to be taken of your child during event activities? *

Yes

No

Do you give permission for these photos to be used for publicity purposes? *

Yes

No

Do you give permission for the above details to be held after the event? *

[This means you don't have to fill this form out again!]

Yes

No

May we use these details to contact you about other, similar events in future? *

[i.e. future holiday clubs]

Yes

No

I give consent for the child named above to participate in the above mentioned event and I acknowledge the need for acceptable responsible behaviour on her/his part. I understand that while involved s/he will be under the control and care of the group leader and/or other adults approved by Bury Parish Church and that, while those in charge will take all reasonable care of the children, they cannot necessarily be held responsible for any loss, damage or injury suffered by her/him during, or as a result of, the activity. In an emergency and/or if I am not contactable, I am willing for her/him to receive necessary hospital or dental treatment including an anaesthetic. *

Yes

No