Parent/Guardian Information

Parent/Guardian's First Name*

Parent/Guardian's Last Name*

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Parent/Guardian Information

Address Number and Street*

Address Town*

Address Postcode*

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Parent/Guardian Information

Phone 1* (Mobile preferred)

Phone 2 (Optional)

Phone 3 (Optional)

Email*

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Child's Information

Child's First Name*

Child's Last Name*

Languages Spoken at Home (Optional)

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Child's Information

Child's Day of Birth*

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Child's Month of Birth*

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Child's Year of Birth*

20112012201320142015201620172018201920202021 Back Next

Child's Information

(Leave blank those that do not apply)

Details of any medical condition your child has which we should be aware of:

Details of any Special Needs your child experiences:

Details of any allergies your child has:

Details of any special dietary requirements your child has:

If your child self-medicates then please ensure your child brings to every activity their inhaler, EpiPen, etc.

Please list the self-medication your child will bring with them:

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Statement of Permission

Please check the following boxes where appropriate:

I give my permission for photographs to be taken of my child and/or me for use as display within the building.

I give my permission for my child's birth date to be kept for birthday celebration during the activities.

I give my permission for my contact details to be used by Hayes Town Chapel to provide additional information. Your contact details will not be passed on to third parties and you may change your answer at any time by informing the activity leader.

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Child Pick-Up

We are not responsible for the children before drop-off or after the activity finishes. In the event of any other adult collecting your child(ren), please fill in their details and a password that they will be expected to know to authenticate them when collecting your child(ren):

Nominated Person 1 of 3: (Optional)

Full Name:

Relation to the child:

Password:

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Nominated Person 2 of 3: (Optional)

Full Name:

Relation to the child:

Password:

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Nominated Person 3 of 3: (Optional)

Full Name:

Relation to the child:

Password:

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Parent/Guardian Signature

Parent/Guardian Full Name*:

Date of this Signature*:

Please ensure you come with your child on their first attendance so the activity leader can run over any questions on the form with you and confirm your electronic submission.

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