Buzykidz (After school club setting) Registration Form & Health Details

This form is very important and it would be appreciated if it is filled accurately.

PLEASE FILL IN BLOCK CAPITALS.

First Child's Name: ..........................................................DOB.............................................

Second Child's Name:..........................................................DOB.............................................

Start date: ............................. Name/Address of School: ................................................................

Address of Parent/Guardian: ......................................................... Religion ..............................

Telephone (home) .............................. Telephone (work/mobile): ..............................

Emergency Contacts.

Name :............................................................

Relationship to child: .........................................

Name of Employer: ............................................................

Contact number: ......................................... Password to collect: ........................................

Doctors details............................................................

Name............................................................

Name of Surgery & Address: ................................................ Telephone number: ..........................

ALLERGIES

My child have the following allergies:

First Child (name)............................. Allergies .....................................................

Previous Medical History:.....................................................

MY CHILD IS ALLOWED PLASTERS YES / NO

MY CHILD IS ALLOWED PLAIN WIPES ON A GRAZE IF REQUIRED YES / NO

Any other comments that may be relevant.....................................................

Dietary requirements:.....................................................

Please indicate how many days you would like your child to attend buzykidz Sessions Required:

Sessions	Monday	Tuesday	Wednesday	Thursday	Friday
After School