Wildwood days booking form

Which event are you booking for?

Child Information

Child's name

First Name Last Name

Date of birth

Month Day Year

Gender

Male Female

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Mobile Number

E-mail

I would like to sign up for the email newsletter

Yes No

Emergency Information

Emergency Contact's Name

First Name Last Name

2nd Emergency Contact's Name

First Name Last Name

Contact's relationship to the child

2nd contact's relationship to the child

Emergency contact's landline

Area Code Phone Number

Emergency contact's mobile

2nd contact's mobile

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the child prescribed an inhaler? If yes, please explain any instructions.

Does the child carry an epi-pen and, if so, is it possible to bring 2 in case of severe reactions?

I am happy for Wildwood Days to use photographs of my child on their website and Facebook page (children are not named in any photos)

Yes No

I am happy for Wildwood Days staff to administer sun cream and/or insect repellent to my child if necessary.

Yes No

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Event booking form