Please confirm which dates you would like to book your child/young person in to the holiday club *
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Does your child require a 1:1?
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If yes and they already have a 1:1 who will work with them, please provide their name and contact details below.
Child’s Name (in full)
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First Name
Last Name
Child’s Address including Postcode
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Is your child a Nottinghamshire County Council or Nottingham City Council resident?
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Date of Birth
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School Attended
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Does your child receive free school meals?
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Home Language
Religion
Ethnicity
Name of Parent/Carer
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First Name
Last Name
Relationship with Child
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Email
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Telephone Contact - Day, Evening, Mobile
*
(###)
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Emergency Contact 1 (Name, Number and Address)
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Emergency Contact 2 (Name, Number and Address)
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Names of people who will collect the child
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(children will only be allowed to leave with a named person)
Child's Doctor
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Doctor’s Address, Postcode & Telephone No.
Does your child have any known medical problems, disabilities or allergies? (please give details)
Does your child take any prescribed medication? If so, please note its name, the dose and the reason they are taking it
Will they need help to take medication whilst at the club?
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Has your child had their pre-school booster?
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Plasters (Band aids) can cause an allergic reaction in some people. We can only apply a plaster to a cut or graze if we have the parents/carers consent. (please check one box)
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I consent to any emergency medical treatment necessary during the running of the club. I authorise the playworker staff to sign any written form of consent required by the hospital authorities if the delay in getting my signature is considered by the doctor to endanger my child’s health and safety.
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Photo permission: I give permission for the club to use photographs of my child
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Video permission: I give permission for the club to use videos of my child
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Local Visits: I give permission for the club to take my child out on local visits
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In order to update the administration functioning of our club we propose to use a computerised database which will hold the basic information for users of our club. In order to comply with the data protection act we require your authorisation to keep your child’s/children’s record on the database. I give permission for my child’s details to be held on Look inside’s database.
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Signed
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Date
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DD
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Your booking request has been sent, we will confirm your booking shortly. If you have any questions, please email selina@lookinside.org.uk
