Wildwood days booking form

Which event are you booking for?

Child Information

Child's name

First NameLast Name

Date of birth

MonthDayYear

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Mobile Number

E-mail

I would like to sign up for the email newsletter

YesNo

Emergency Information

Emergency Contact's Name

First NameLast Name

2nd Emergency Contact's Name

First NameLast Name

Contact's relationship to the child

2nd contact's relationship to the child

Emergency contact's landline

Area CodePhone 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)

YesNo

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

YesNo

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