St Mary & All Saints Church Beaconsfield

Champions Challenge 2008

St Mary and All Saints Church Holiday Club

11 - 15 August 2008

Registration Form

Name of child_____________________________________ Age _____Date of Birth____________

Address________________________________________________________________________

_____________________________________________________ Postcode__________________

Telephone_Mobile__________

Email___________________________________________________________________________

(Name of child)_____________________goes to __________________________ School (Year___)

and attends ____________________________________ Church/Sunday school

Would you be happy for photographs/videos of your child to be taken during the Holiday club for you to purchase and/or publicity for the Holiday Club? Y/N

Please indicate the days your child will be attending by ticking the appropriate boxes below. Priority will be given to those children able to attend all 5 sessions.

Monday

Tuesday

Wednesday

Thursday

Friday

I enclose a fee of £_____ ( £2 per session) – cheques payable to St Mary’s Holiday Club

My child will be collected by (print name) ____________________________Tel________________

MEDICAL INFORMATION

Does your child suffer from any illnesses, disability or condition that might be affected by this activity?

Please specify____________________________________________________________________

Does your child require any medication?________________________________________________

Does your child suffer from any food allergies? (please specify)______________________________

I give permission for any emergency dental, medical or surgical treatment, including anaesthetic, as considered necessary by the first aiders/medical authorities present.

Emergency contact – in the event that you are unavailable

(Name)__________________________________________Tel:_________________________

Signed ___________________________________Parent/Guardian Date _________________

The Holiday club reserves the right to refuse admission to any child. The club also reserves the right to ask a child to leave the club should their behaviour be considered, in their opinion, unacceptable.

PLEASE RETURN THIS FORM TOGETHER WITH YOUR FEE and SAE to:

St Mary & All Saints Holiday Club c/o 139 Holtspur Top Lane, Beaconsfield HP9 1BW

Office Address:

Windsor End,

Beaconsfield,

Buckinghamshire,

HP9 2JW