Before and After School Club Admissions

Please select the club you wish to register for: *

Child's Name: *

First

Last

Address: *

Post Code: *

Date of Birth: *

Please provide details of any known medical problems/additional needs:

Please provide details of any specific dietary needs / known allergies /other:

Please tell us your child’s first language, religion & culture: *

1. PARENT/CARER NAME: (Please state the name of who has legal contact and who has parental responsibility for your child): *

Relationship to Child: *

Parent/Carer Address: *

Parent/Carer Contact Number (Home): *

Parent/Carer Contact Number (Mobile): *

Parent/Carer Contact Number (Work): *

Emergency Contact? *

Yes
No

2. PARENT/CARER NAME: (Please state the name of who has legal contact and who has parental responsibility for your child): *

Relationship to Child: *

Parent/Carer Address: *

Parent/Carer Contact Number (Home): *

Parent/Carer Contact Number (Mobile): *

Parent/Carer Contact Number (Work): *

Emergency Contact? *

Yes
No

Alternative Emergency Contact Full Name:

Relationship to Child:

Alternative Emergency Contact Address:

Alternative Emergency Contact Number (Home):

Alternative Emergency Contact Number (Mobile):

Alternative Emergency Contact Number (Work):

Doctor's Name: *

Doctor's Address: *

Doctor's Contact Number: *

Before School Club – (Please select days required – excl. Little Thurrock):

After School Club – (Please select days required):

Please provide a preferred Start Date: *

Please provide any information that will support your child whilst in our care:

Please provide a Security Password (All new persons collecting your child will be asked for this) *

To help us see how well our 'Equal Opportunities Policy' is working it would be helpful if you would select which Ethnic group your child belongs too (Optional):

If you selected 'Other' please state below:

I give permission to allow my child to have: *

Emergency Medical advice or treatment if necessary and I have read the Terms & Conditions and I am happy with the procedure that would be followed?
Photographs taken for promotional purposes including website, social media sites, club displays and portfolios. Also allowing the photos to continue to be used once the child has left the setting?
General hygiene chats and toiletries supplied as appropriate?
Sun cream applied by a member of staff if necessary?
Face paints applied?
None of the above

In line with the 'General Data Protection Act 2018' please provide an email address to receive invoices, promotional emails and newsletters from us: *

I agree to abide by all of the Terms & Conditions and Policies and Procedures laid out by Jules et Lis Out of School Clubs? *

Agree

Name *

First

Last

Date *

Before and After School Club Admissions

Before and After School Club Registration Form