Kingsbury Community Leisure Centre

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					Local Services Directorate

       Kingsbury Community Leisure Centre

                  October 2007

Kingsbury Arts Workshops
and Playscheme     Mon 22nd – Friday 26th October 8 – 12yr olds
                   Forms attached

Activities within the area

   Kids’ Self Defence and circus skills at Yenton Primary, contact Kate
      07825 052057
     FREE 5 Aside Football at Star City (must be resident in Erdington
      Hall) contact Kate 07825 052057 or Anita 0121 464 0220
     Pype Hayes Focus Playscheme Contact 0121 464 6104
     Lyndhurst Activities contact Community Shop 0121 382 6266
     Halloween crafts at Erdington Library on Saturday 20th October.
      2.00-3.00pm, drop-in session. Children of all ages welcome. Under 8s
      need to be accompanied by an adult.
                                        Kingsbury Community Leisure Centre
   accompanied by an adult              Kingsbury Road, Erdington,
                                         Birmingham, B24 8RE
                                         0121 – 306 - 4874
                                         Centre Manager – Tracy Stevens
                         Kingsbury Community Leisure Centre

           Arts Workshops and Playscheme - 2007

Centre Manager: Tracy Stevens          - 306 4874

Children aged 8 – 12 years old (younger children may come if accompanied by a parent)

Monday 22nd – Friday 26th October 2007, as follows:
Monday, Wednesday and Friday: Arts Workshops
Tuesday and Thursday – Playscheme : “Junk Funk”, Arts/crafts, and
drama/dance/storytelling. There will be a Halloween theme and places to each workshop
will be allocated on arrival. You should be able to try out all three workshops during the
with arts/crafts and Halloween activities
Please drop your child off at 9.45am and pick up promptly at 3.00pm.
Lunch will be for approximately ½ hour. You will need to provide a packed lunch and plenty
of drinks for your child.

Arts Workshops: £4 per day, Playscheme: £3.50 per day - per child (half price for 3rd /
4th or more siblings). You are welcome to attend as many or as little days as you like
providing notification and payment is in advance. An Application Form must be completed
for each child individually, and either pay in full or a deposit of £7 must be made in
advance of the scheme. (Cheques made payable to: SAFE Community Group) Forms to be
returned to Kingsbury Leisure Centre by   Friday 12th October

      Arts Workshops: “Junk Funk”, Arts/crafts, and drama/dance/storytelling. There
       will be a Halloween theme and places to each workshop will be allocated on arrival.
       You should be able to try out all three workshops during the 3 days.
      Playscheme: Each day will have a variety of activities e.g Games, Halloween
       activities, Arts & Crafts. Board Games & Colouring will be available throughout the

     Application Form (one to be completed per child)
        Registration / Payment Form
              Kingsbury Community Leisure Centre

(One child per form)

Childs Name: _____________________________________                                       Age: _________

Date Of Birth: _______ Gender: ________ Childs School: _______________

Parent/Carer Name: ______________________________________________

Address: _________________________________________________________

Post Code: ___________

Home Tel. No: _____________________ Mobile No: ____________________

The following information is required for monitoring purposes and will be kept secure and confidential:

       WHITE                        BLACK                       ASIAN                     OTHER ORIGIN
 UK     Irish      Oth      Carib    Afri    Oth      India   Pkst  Bang        Oth      Chin Viet  Oth

    Asn/Blk              Wht/Blk       Wht/Blk/Afri       Wht/Blk/Carib            Oth               Total

EMERGENCY CONTACTS (please list someone other than parent/carer completed above – we will always try to
contact the above mentioned first).

Name: _______________________ Relationship to Child: _______________

Home Tel: ___________ Work Tel: ___________ Mobile No: _____________

Name: _______________________ Relationship to Child: _______________

Home Tel: ___________ Work Tel: ___________ Mobile No: _____________

Continued …

Doctors Name: ____________________________________________________

Address: _________________________________________________________

Tel. No: _____________________

Please list any medication used: ______________________________________
If your child needs to administer medication while at the playscheme, please inform the playscheme

Please list any food stuffs your child must not eat/drink: ___________________
Please state if your child has any allergies/medical or social needs the provision needs to
be aware of:_______________________________________________
All playschemes have staff who are qualified first aiders and if needed, may administer
basic first aid. Please tick the box if you DO NOT wish your child to be treated
You will be contacted immediately in the event of an accident requiring hospital treatment. I consent to
my child receiving any emergency treatment, Dental, medical or surgical, including the administration of
anaesthetic that might be advised by a doctor during the time that my child is attending the centre.

Signed: ____________________ Print: __________________ Date: ________

Relationship to child: _______________________________________________

Address if different from child : ______________________________________

As part of this scheme, photographs may be taken by an appropriate employee of the Playscheme for the
purpose of recording an activity/event. These may be displayed in photo albums/display material within
the centre in relation to the activity/event and will not be used for any other purpose. Should you object
to this, please inform the Playscheme co-ordintor.

The centre has a legal responsibility to report to the designated Social Services Officer details of any child

who we suspect may have been abused or neglected.

I agree to my child taking part in activities of the centre, whilst in the care and supervision
of a member of staff.

Signed: _____________________ Print: _________________ Date: ________
The above information will be stored by play scheme co-ordinators for a period of up to 3 years for administration
purposes only.
                               Kingsbury Community Leisure Centre


To secure a place for your child, you must complete the Application Form, and
the following Payment Form and return it to us as soon as possible as places
are allocated on a first come, first served basis.

I ______________________ (parent/carer) would like my child:

                   (childs name) ___________________________

to attend the following days:-
(Please tick as appropriate)

        Monday 22nd Oct                  £4

        Tuesday 23rd Oct                 £3.50

        Wednesday 24th Oct               £4

        Thursday 25th Oct                £3.50

        Friday 26th Oct                  £4

I have completed the relevant forms and include £4.00 for each Workshop day and/or

£3.50 for each Playscheme day, or a deposit of £7 required, of which the total is

£ ________.
(cheques made payable to: SAFE Community Group)

Signed: _____________________ Print: _________________ Date: ________