Forms SEND Friendly Christmas Activities Form HAF Code * *HAF codes are needed to book a session (codes can be obtained via the Nottinghamshire County Council Customer Service Centre) Please confirm which time slot you would like to book for your child/young person (please only select ONE slot) * 12pm - 1pm 1pm - 2pm 2pm - 3pm 3pm - 4pm Child’s Name (in full) * First Name Last Name Child’s Address including Postcode * Is your child a Nottinghamshire County Council or Nottingham City Council resident? * County City Other Date of Birth * School Attended * Does your child receive free school meals? * Yes No Name of Parent/Carer * First Name Last Name Relationship with Child * Email * Telephone Contact - Day, Evening, Mobile * (###) ### #### Emergency Contact 1 (Name, Number and Address) * Emergency Contact 2 (Name, Number and Address) * Does your child have any known medical problems, disabilities or allergies? (please give details) 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) * Yes, I give Look inside permission to apply a plaster to my child No, I do NOT want my child to be given a plaster Photo permission: I give permission for the club to use photographs of my child * Yes No Video permission: I give permission for the club to use photographs of my child * Yes No 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. * Yes No 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. * Yes No Signed * Date MM DD YYYY Thank you!
