Rotherham Childcare Provider
Welcome to Wickersley After School Club and Holiday Club
Serving the Rotherham Area
Admissions Form
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Child's Details
Name of Child
House Number/Name & Road Name
Area
Town
PostCode
Date of Birth (dd/mm/yy)
School Attending
Parent/Carer Details
Parent/Carer Name (* required field)
Home Tel:
Work or Mobile Number
Email Address (* required field)
Please enter Email Address again
Medical Details
Doctors Name
Doctors Address 1
Address 2
Address 3
Address 4
Doctors Tel:
Details of significant health issues Include Special Educational Needs and or physical disabilty
Details of Food Allergies or Dietry Needs
Do you authorise the Manger to consent to emergency treatment on your behalf in the event of your child requiring treatment at the hospital and you cannot be contacted?
Yes
No
Do you consent to members of staff applying sun cream to your child if required?
Yes
No
Do you consent to your child's photo being taken during the course of club activities
Yes
No
Do you accept all the terms and conditions set out in the clubs policies and procedures?
Yes
No
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