Cup Cakes Club Admission Form 2012 v0 1 by CQEc64cf

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									CUP CAKES CLUB APPLICATION FORM
Thank you for choosing to apply for your child to attend our club. In order to be able to offer you a
place, we need to gather some information about your child and you. Please, complete all the
sections applicable to you in BLOCK letters.
Under the Data Protection Act October 2001 I need to inform you that the information you have
given about yourself and/or your child will be kept for the purpose for which it has been given.
CONFIDENTIAL
CHILD'S DETAILS
Name:                                Surname:
Date of Birth:                       Sex:
Address:


GP Name:
GP Address:

GP's Contact Tel No:
School Attended at Requested Start Date:                                       Class:
REGULAR or AD HOC?:                                       Requested Start Date:
For Regular please tick relevant boxes  Mon   Tue         Wed        Thu       Fri
Breakfast Club                7:45-9:00
Afterschool Option 1 3:15-4:30
Afterschool Option 2 3:15-5:45
Afterschool Option 3 3:15-6:45
Afterschool Option 4 4:30-5:45
Holiday Club: Please, fill in holiday booking section at the end of this form.
MEDICAL DETAILS
Does your child have any known medical conditions? (Please list)



Does your child have any allergies? E.g. peanuts allergies, plasters,face-painting etc. (Please list)



Please, tell us about any special dietary requirements.



Please, tell us about any special educational needs/s and/or disabilities that your child has.



PASSWORD
Please, write down the password to be used whilst your child is being collected.

FIRST CONTACT
Name:                                Surname:
Relationship to child:
Address:

Telephone numbers:       work:                               e-mail:
                         home:
                         mobile:
SECOND CONTACT
Name:
Relationship to child:
Address:

Telephone numbers:          work:                                   e-mail:
                            home:
                            mobile:
THIRD CONTACT
Name:
Relationship to child:
Address:

Telephone numbers:       work:                              e-mail:
                         home:
                         mobile:
The Club will contact the people in the given order above if a need arises.
OTHER IMPORTANT INFORMATION
Please use the space below to tell us any important information (eg. Court orders etc.)


Are you in receipt of Working Families Tax Credit? (Yes/No)
CONSENT
Some of the club's routine activities may involve visiting parks or short trips including the use of
transport. For your child to take part in these activities, you must give your permission.
Do you agree to your child taking part in the activities described above? (Yes/No)
Comments:

Do you consent any emergency medical treatment necessary during the running of the club?(Yes/No)
Comments:

Do you authorise the staff to sign any written form of consent required by hospital authorities if the delay
in getting your signature is considered by the doctor to endanger your child's well-being?(Yes/No)
Comments:

Do you grant permission to Cup Cakes Club to use your child's photograph, image or voice for the purpose
of publicizing Cup Cakes Club in any of its advertisements, videos, CDs, displays?(Yes/No)
Comments:

The information provided is accurate to the best of my knowledge. I have read the Parents'
Prospectus and agree and abide by the rules regarding my child's membership of the club.
Print Name:                                                            Date:
Signature:
MONITORING INFORMATION
Please specify which ethnic category best describes your child using the list given below:
This will assist us in ensuring that we are meeting the needs of our community.
a) Asian or Asian British: Indian, Pakistani, Bangladeshi, Any other background.
b)Black or Black British: Caribbean, African, Any other Background.
c) Chinese or Other ethnic group
d) Mixed: White and Black Caribbean, White and Black African, White and Asian
e) White
Please, specify which category best describes your reasons of using the club:
Working Parents                                        Studying Parents
Parents returning to work or study                     Families in Needs                       Other

								
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