Out of School clubs

St. Andrew’s C.E. Primary School

Out of School Clubs Admission Form
Please complete all parts of this form and return to St. Andrew’s School
Child’s Surname: Child’s Surname:
Chosen Names: Date of Birth:
(yyyy-mm--dd)
Gender M/F
Name of parent/carer:
Home Address of child:
Post Code:
Telephone number:
1st Priority Emergency Contact
Name:
Address:
Telephone:
Relationship to child:
2nd Priority Emergency Contact:
Name:
Address:
Telephone:
Relationship to child:
Names of people who can collect:
My child will attend the following sessions (please circle as necessary)
Breakfast club times:  Monday-Friday  7.45-9.00am  cost £2.75 per day (discount available for breakfast club only-please enquire)
Monday Tuesday Wednesday Thursday Friday
              
 

After school Club times : Monday – Friday 3.15 –6.00pm  cost £6.50 per day
Monday Tuesday Wednesday Thursday Friday
 

Full contact details, address etc., must be provided for all other people who may collect your child (please list on a separate sheet if necessary and attach):
Medical Information:
General Practitioners Name:
Address of Doctor:
Telephone number:
National Health Service Medical Card Number:
Details of any medical condition requiring medical treatment:
Details of any special requirements (diets, allergies, access requirements, religious requirements):
Any additional details
Declaration:
 I have read the information provided and I give my permission for my child to attend the days indicated.
I understand that I will have to pay for all sessions booked, whether or not my child attends, and if I wish to cancel the booking I will have to give four weeks notice in writing
 Yes /  No (please delete as necessary)
In the event of emergency medical treatment being required I give my permission for a staff member to arrange emergency health care if a parent or carer cannot be contacted.
Signed:
Name (print) Date of application: