Pop-up Football - St Andrew's Livesey

EASTER Secret Agents!

Parent/Guardian's Name *

First

Last

accident will this

Parent/Guardian's Contact Number *

If there is an emergency we will try and reach you on this number, before calling the Reserve Emergency Contact (see below)

Parent/Guardian's email address *

Child's Name *

First

Last

Child's Date of Birth *

E.g. 01/01/2016

Male/female *

Any medical conditions or allergies we should be aware of *

E.g. asthma

Home Address *

How did you hear about Secret Agents?

As parent/guardian, I give permission for my child named on this form to take part in this Holiday Club. I understand that while involved my child will be under the care and supervision of St. Andrew's Livesey Church. St Andrew's Livesey church are under no liability for loss or damage to personal property. Every effort will be made to contact me should my child become ill or have an accident. I give permission for medical treatment in the event of illness or accident if I cannot be contacted, and in the case of an emergency. *

At the end of the morning, how will your child get home? *

I will collect them
Another adult will collect them (enter name below)
I give permission for them to walk home alone

If another adult will be collecting your child, enter their name(s) here

St Andrew's Livesey church may take photos or videos of the activities as a record and to celebrate the event. May we use your child's image in photos and videos for various media produced? Your child's name will not be used. *

Yes, I give permission
No, I do not give permission

I understand that this information is being collected to enable the safe and smooth running of the Holiday Club. St. Andrew's Livesey would also like to contact you occasionally with news of upcoming events for children and young people. Are you happy for your contact details to be stored and used for this purpose? *

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