Child's Full Name
Child's Date of Birth (DD/MM/YY)
Child's Gender (male or female)
Potential Start Date (DD/MM/YY)
Names of any siblings also using the club:
School attended and Class Number
Child's Medical Info
Doctor’s phone number
Please list any known medical problems
Please list any additional needs
Please list any medication taken
Please list any known allergies
Please list any dietary requirements
Please list any further relevant health information
Parent/Carer 1 (Bill Payer) Details
Relationship to Child
Parent/Carer 2 Details
Please Select 'YES' or 'NO'
Does parent/carer 1 have parental responsibility?
Does parent/carer 2 have parental responsibility?
Does anyone else have parental responsibility for this child?
If 'YES' Please provide details below
Details of Person With Parental Responsibility
Details of other person authorised to collect in absence of parent(s)*
In the event of somebody else collecting your child we require a password to release your child.
All staff are trained to ask for this password if they do not recognise the person collecting your child.
Emergency Contact Details - Please Provide 2 People
Child's Preferences & Permissions
Is your child permitted sweets/cakes?
Are you happy for your child to have party foods on birthdays and other festivals?
Is there anything your child does not like (food, games, etc) or is scared of?
Any special dietary requirements / food allergies?
What are your child’s favourite activities?
Booking Pattern & Payment
PARENTS MAY CHOOSE ADHOC DAYS FOR BREAKFAST AND AFTER SCHOOL CLUB
Concordia Breakfast Club Booking Pattern
Breakfast Club - 7am – 8.30am @ £3 per session
Concordia After School Club Booking Pattern
3pm – 6:30pm @ £12 per session - Please tick required days
Please select BACS Weekly/Monthly or Vouchers
BACS MonthlyBACS WeeklyVouchers
N.B. By selecting a paymet option you are agreeing to the following terms;
- Payments to be made in advance for pre-booked contracted days
- Administration fee of £25.00 to be paid on application
- Refundable Deposit of £100.00 payable which is refunded upon 2 weeks paid notice of termination of contract
Activity Terms & Permissions
Some of the routine activities of the club may involve physical play activities, visiting parks, short trips & day trips.
Minor accidents will be expected through the very nature of participating in play.
All activities are risk assessed and properly supervised.
For your child to take part in these activities you must give your permission below;
I agree to my child taking part in the routine activities
I agree to make payment for outings & provide spending money if required.
I agree to the Co-ordinator or Manager to act appropriately in an medical emergency:
Application of Sunscreen
Children love to play outside in the sun, but sunburn in childhood increases the risk of developing skin cancer in later life.
Please select whether you will be using the Club's or providing your own sunscreen
I am happy for my child to use the sunscreen provided by the Club.I will provide a bottle of sunscreen labelled with my child’s name for use at the Club.
Photography & Video Consent
In-house wall displays
School Club Website using facial images
School Club Website (Non-facial)
School Club Facebook page (Non-facial)
School Club Facebook using Facial images
Promotional literature booklets
Local press releases
General Data Protection Regulation Compliance
In order to meet our requirements under GDPR we will ensure that parents are provided with our privacy notice and data sharing agreement.
We confirm that we will not share or use your data for other purposes other than what is outlined.
*Our GDPR is available by clicking here (opens in a new window).
Please confirm that you accept the privacy notice and data sharing agreement and that you give your permission for us to contact you regarding relevant matters.
I accept the privacy notice and data sharing agreement
Terms & Conditions
*Our terms and conditions are available by clicking here (opens in a new window).
I have read the terms and conditions and agree to them
This form is from the register for Concordia page.