Name of Child *

D.O.B. *

School Year (as at July 2022) *

Parent / Carer Name *

Parent / Carer Email *

Parent / Carer Phone *

Emergency Contact Name *

Emergency Contact Phone *

Address *

City/Town *

Post Code *

Medical Information / Allergies *

Can we administer first aid to your child if necessary? * Select ... Yes No

I give consent for pictures of my child to be taken and used for publicity on church premises, social media / Facebook and local press. * Select ... Yes No