Easter Registration Form

DKHAP EASTER PLAY SCHEME REGISTRATION FORM
DATE: Monday 3rd of April - FRIDAY 13th of April 2017

DROP OFF: 9.00 am

PICK UP: 6.00pm

COST: £25 per day, per child. 3rd child attends free of charge

DEPOSIT: £25/CHILD payable by 24th of March
Information of Child/ren
1.Childs name

First NameLast Name
Gender

MaleFemale
School year
Birth Date

MonthDayYear
2.Childs name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
School year
3.Childs name

First NameLast Name
Gender

MaleFemale
3.Birth Date

MonthDayYear
School year
Address

Street Address

Street Address Line 2

CityState / Province

Post code
Allergies, illness, Challenging behaviour,or medical conditions? If yes, please describe.
Parent/Guardian Information
Name

First NameLast Name
Home Number
Mobile number
Address

Street Address

Street Address Line 2

CityState / Province

Post codeCountry
E-mail
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Post codeCountry
Alt. Phone Number
BOOKING INFORMATION

Week 1

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
PLEASE SELECT

Week 2

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY
PLEASE SELECT

Do you give permission for staff to take photos of your child?*

	yes	no
1. May we use your child’s image in our printed promotional publications?
2. May we send out your child’s image with our press releases?
3. May we use your child’s image on our website?
4. May we record your child’s image on our promotional videos?
5. May we record your child’s image on our Facebook/Instagram page?

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.
Signature

Clear
Should be Empty:

DKHAP EASTER PLAY SCHEME REGISTRATION FORM