Full Name of Person filling in this form: *
Relationship to Participant: * Father
Mother
Guardian
18 or over and coming myself
Declarations (Registration is only valid if box is ticked): * I, the person filling out this form, being the parent/guardian or young person 18 years or over give permission for him/her to take part in the event named above. I have read the details given regarding the event and understand what is involved. I acknowledge the need for obedience and responsible behaviour on his/her part throughout the period and the need for him/her to take special note of any safety instructions. I am satisfied that all reasonable care will be taken for the safety of those participating and that adequate staffing and other insurance and safety measures have been taken. I understand that my son/daughter will not be able to participate unless this form has been returned and completed by me. I also understand that during periods of free time close supervision by leaders may not be possible at all times. I consider my son/daughter to be medically fit to participate in the activities outlined. I agree to my child receiving emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present. I understand that every reasonable effort will be made to contact me. I understand that any information given on this form will be treated in confidence and only used if necessary and that inadequate information could put my child’s life at risk.
The person to contact in case of emergency during this event is: *
Relationship to Participant: *
Address: *
Contact numbers (Day, Evening, Mobile?): *
Give contact details of second person (if above cannot be reached) : *
Give Name, Address and Tel.No. of doctor: *
Full Name of person coming to Hill End : *
Gender: * Male
Female
Date of Birth: *
House Number & Street Name: *
Town: *
Postcode: *
Email Address: *
Contact number:
Are you registering as a helper?: * No
Yes
I will pay the fees to 'Well Street United Church' as follows:: * £35 via cheque by post
£35 on the day of arrival
£20 (helper only) via cheque by post
£20 (helper only) on date of arrival
I cannot afford to pay, please contact me
Are you vegetarian or have you got any other dietary requirements?: * No
Yes (please give details below)
Please give details of dietary requirements:
Do you have any specific allergies, medical issues or disabilities that need to be made aware?: * No
Yes (Please give details below)
Please give details of any allergies, medical issues or disabilities :
Has the participant an allergy, medical issue or disability that may be of concern to us, (The Hillend Team)? : * Yes (continue with this form)
No (you are done! Go to the bottom of this form, enter the verification number and click SUBMIT)
Medical concern:
Current medication:
Current dosage:
Any other relevant information:
Consent for administering medication: I agree that in the event my child is not able to self administer the above medication, I hereby consent to the administering of the above medication by a trained first aider of Hill End Team (Well Street United Church) in accordance with the details given here.
Please enter the verification number on the right:*
* Required Fields
