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Ashgate Croft After School Holiday Club

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Ashgate Croft After School  Holiday Club Powered By Docstoc
					                             Ashgate Activity Club

Please send completed form to: Miss Laura Cousins – Supervisor, Ashgate Activity Club,
c/o Ashgate Croft School, Ashgate Road, Chesterfield S40 4BN

     07984 882714
    email: laura@ashgateactivityclub.co.uk or ashgate_activity@yahoo.co.uk

                                       Application Form
                (please print clearly)
:………………………………………………… Daytime
  1. Name:………………………………………………………………………………………...

  Address:………………………………………………………………………………………...
  …………………………………………………………………………………………………..
  …………………………………………………………………………………………………..
  …………………………………………………… Post Code:…………………………….….

  Telephone Numbers: ………………………………………………… Daytime
                     ………………………………………………… Evening
                     ………………………………………………… Mobile
                     ………………………………………………… Emergency Contact
                                         Name & Number


  2. Age:……………………………………… 3. Date of Birth:……………………………..


 4. Ethnic Origin e.g. cultural needs & beliefs:           5. Religion




  6. What are the particular additional needs / disabilities of your child / young person?
  (e.g. Autism, ADHD, learning disabilities):




  7. What are your child / young person’s likes / dislikes? (e.g. painting, sticking, etc)




  8. Does your child / young person have any fears / anxieties, and if so, how do you as a
  parent / carer manage this?



Version May 2008
                              Ashgate Activity Club
 9. Please give any other medical information (including
:………………………………………………… Daytime any allergies) that may be
  relevant also all details of medication taken:-
  PLEASE NOTE: ALL MEDICATION MUST BE CLEARLY LABELLED




  10. What activities does the person enjoy or not enjoy:-




  11. Food preferences (e.g. vegetarian, special diet)




  12. Please list any relevant information with regards to feeding, dressing, toileting,
  mobility, etc.




13. Please give two contact numbers in case of emergency (including home/mobile)
 1 Name                                 Relationship to child / young person

      Home tel no                        Mobile tel no

 2 Name                                  Relationship to child / young person

      Home tel no                        Mobile tel no

 GP name                                 Surgery tel no

 Surgery address



Version May 2008
                            Ashgate Activity Club
 14. Do you have any objection to photographs including
:………………………………………………… Daytime the young person being used for
  publicity?

                   Yes         No 



  15. Is there any other information we may need to know such as communication needs,
  toileting needs , moving and handling needs etc




  16. Please note that there is a (non-refundable) £1.00 joining fee per child.




  17. All the information I have given is correct, and I would like ……………………………
  to be considered for a place at Ashgate Activity Club.            (Name of young person)

  18. In the event of an emergency where I can not be contacted, I give consent for
  medical treatment to be administered to my child.

  Signed:-………….………………………………………………………………………………

  Print Name:-……………………………..………………………………………………………

  Relationship to person:-…………………………………………………………………………

  Date:-……………………………………………………………………………………………




Version May 2008

				
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Description: Ashgate Croft After School Holiday Club