Holiday Activities Contact and Health Form

"To provide high quality PE and sport provision to enrich the lives of all young people"

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- Step 1 of 6

Name of person filling in this form *

Relationship to young person/people you are filling the form for *

E.G. Mother, Father, Guardian, Other

Please confirm what venue(s) you have booked for *

Congerstone Primary
Desford Primary School
Nethersole C of E Primary School

How many children are you filling this form in for *

Name of main emergency contact *

Phone Number of Main Emergency Contact *

Email Address of Main Emergency Contact *

Name of Second Emergency Contact

In case we are unable to get hold of the main contact a second emergency contact is required.

Phone Number of Second Emergency Contact

In case we are unable to get hold of the main contact a second emergency contact is required.

Email Address of Second Emergency Contact

In case we are unable to get hold of the main contact a second emergency contact is required.

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Child Full Name *

Child Date of Birth *

Address and Postcode of Child

Does your child have any medical conditions? *

If Yes, please give details about their medical conditions.

Include any allergies

Does your child have any SEND? *

If Yes, please give details about their SEND requirements

Does your child have any dietary requirements? *

If Yes, please give details about their diertary requirements

Include any allergies

We may look to take photo's that will go on our social media. Do you consent to photo's being taken of your child? *

Is there any other information that could be helpful?

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Child 2 Full Name *

Child 2 Date of Birth *

Address and Postcode of Child 2

leave blank if same as other child or children

Does child 2 have any medical conditions? *

If Yes, please give details about their medical conditions for child 2

Include any allergies

Does child 2 have any SEND? *

If Yes, please give details about their SEND requirements for child 2

Does child 2 have any dietary requirements? *

If Yes, please give details about their diertary requirements for child 2

Include any allergies

Is there any other information that could be helpful about child 2?

We may look to take photo's that will go on our social media. Do you consent to photo's being taken of child 2? *

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Child 3 Name *

Child 3 Date of Birth *

Address and Postcode of Child 3

leave blank if same as other child or children

Does child 3 have any medical conditions? *

If Yes, please give details about their medical conditions for child 3

Include any allergies

Does child 3 have any SEND? *

If Yes, please give details about their SEND requirements for child 3

Does child 3 have any dietary requirements? *

If Yes, please give details about their diertary requirements for child 3

Include any allergies

We may look to take photo's that will go on our social media. Do you consent to photo's being taken of child 3? *

Is there any other information that could be helpful about child 3?

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Child 4 Full Name *

Child 4 Date of Birth *

Address and Postcode of Child 4

leave blank if same as other child or children

Does child 4 have any medical conditions? *

If Yes, please give details about their medical conditions for child 4

Include any allergies

Does child 4 have any SEND? *

If Yes, please give details about their SEND requirements for child 4

Does child 4 have any dietary requirements? *

If Yes, please give details about their diertary requirements for child 4

Include any allergies

We may look to take photo's that will go on our social media. Do you consent to photo's being taken of child 4?

Is there any other information that could be helpful about child 4?

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You may now click the submit button

Thank you for filling in this form, please advise us ASAP of any changes to the details in this form.

PLEASE CALL OR EMAIL OUR FRIENDLY TEAM ON

01455 393404

clubs@coach-unlimited.co.uk

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