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					                       Registration & Consent Form
Child’s Name:……………………………………………………………………………………...

School:……………………………………………………………………………………………..

Address;……………………………………………………………………………………………

Date of Birth:………………………………………………………………………………………

Full name of Parent/Guardian (capitals):……………………………………………………….

Relationship to child:……………………………………………………………………………..

Phone No:………………………Emergency No’s:…………………………………………….

Medical Information:

Does he/she suffer from?      Asthma: Yes No         Hay Fever: Yes No        Diabetes: Yes No
(Please Circle)
                              Epilepsy: Yes No      Migraine: Yes     No

Are they currently taking any medication: Yes       No Details:………………………………

Any known allergies (e.g. Penicillin):…………………………………………………………….

Does your child suffer from any other relevant illness, injury or condition: Yes       No

Details:……………………………………………………………………………………………..

Blood Group (if known)………………………Date of last tetanus injection:…………………

Name of family Doctor:……………………………………………Tel. No:…………………….

Address:……………………………………………………………………………………………

Will your child be:(please tick)

Collected from the school by an adult.

Allowed to make their own way home.

Parent/Guardian’s Declaration: I consent to my son/daughter taking part in S.P.A.C.E, Broadway
Showstoppers dance/drama/singing sessions and declare that my child is in good health and the
information I have supplied is correct. In the unlikely event of an accident occurring when I cannot be
readily be contacted, I give permission for the Party Leader to authorise emergency medical, surgical or
dental treatment, including anaesthetic or blood transfusion, if deemed necessary by the medical
authorities present. I give permission for any photographs of my child to be used in the future for
promotional materials.

Signature of Parent/Guardian:……………………………………. Date:……………………..

				
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posted:9/29/2012
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