Breakfast Club Registration Form

Child's Name *

First Name Last Name

Child's Date of birth *

Day Month Year

Child's Address *

Street Address

Town

Parent/Carer 1 name *

Mr/Mrs/Ms First Name Last Name

Mobile phone number (parent/carer 1) *

Area Code Phone Number

Work phone number (parent/carer 1) *

Area Code Phone Number

Home phone number (parent/carer 1) *

Area Code Phone Number

Parent/Carer 2 name

Mr/Mrs/Ms First Name Last Name

Mobile phone number (parent/carer 2)

Area Code Phone Number

Home phone number (parent/carer 2)

Area Code Phone Number

Work phone number (parent/carer 2) *

Area Code Phone Number

Child's Doctor's Name & Address *

Doctor's Name

Doctor's Address

Town

In the event that the child is involved in a serious incident whilst at the club, I expect the Manager, or a delegated member of staff, to contact me immediately on one of the contact numbers I have given. In the event that the child requires emergency medical treatment before I will be able to get to the hospital I hereby authorise the Manager, or delegate member of staff, to consent to emergency medical treatment on my behalf.

Any other names and contact numbers in case of emergency

Any other relevant medical / dietary information i.e. allergies, family, medical history etc.

Session must always be booked and paid for in advance through the School Gateway App. The club is popular so we recommend booking sessions as far in advance as possible to avoid disappointment as places are limited.

Due to the demand for places, breakfast club will not charge if a child is booked in but is off sick and you have contacted the school, or at least 48 hours notice has been given to the school either by email, text or phone call for any other cancellations.

I understand that this authorisation will remain valid unless I contact the Manager to withdraw it. I have read and agree to the terms and conditions of the club at WRAP Terms & Conditions

Signature of Parent/Carer *

Clear