Buckingham Primary School
Activ-8 Childcare Provision Registration Form
Childs full name______
Date of birth______Age______
Home Address______
______
______
Telephone number ______
Parents name ______
Parents Daytime contact telephone number and address ______
______
Two emergency contact telephone numbers ______
______
Name of school ______
Doctor’s name and telephone number______
Care/Social worker name and telephone number______
______
Any known medical conditions / allergies / special needs? ______
______
______
Is your child on prescribed medication? ______
______
______
In case of serious injury, your child will be taken by ambulance to the nearest casualty department and parents informed as soon as possible.
Do you object to this? YES NO
If YES what action do you wish to be taken? ______
______
______
In case of minor injury your child will be given First Aid by a trained First Aider and parents will be informed when they collect their child.
Do you object to this? YES NO
If YES what action do you wish to be taken? ______
______
______
Snack meals may be provided (Squash, toast, biscuits, fruit etc)
Is there anything you do NOT wish your child to eat? YES NO
If yes please specify ______
______
Photographs and video footage may be taken during session time, these may be used in promotional material for the club / school.
Do you give your permission for your child’s image to be used in this way?
YES NO
We may show a selected PG rated movie, do you give your child permission to watch?
YES NO
We may have water play (pool, slide, sprinkler) do you give your permission for your child to participate.
YES NO
You must make arrangements for your child to be collected or to go home by themselves at the end of the booked session. There will be a charge made for late collection.
Please list names of people who are allowed to collect your child (and inform us on the day if anyone not listed is going to collect them)
______
______
______
Is your child allowed to go home alone? YES NO
(Please note: we are not responsible for children once they leave the site)
Our responsibility is only towards those children who are booked in with us for a session.
The purpose of this form is to collect data for processing within the Activ-8 system. Your signature on this form implies your consent for Activ-8 to process the data. The data will be processed in accordance with the purposes notified by Activ-8 to the Data protection Commissioner’s office and is subject to the Data protection Act 1998. The information given will be entered onto a computer and will form part of Activ-8’s database. Some of the data may be used to promote the interests of Activ-8, i.e. Activ-8 literature/website etc. if you have any objections to this please tick this box
I have read and agree to the ACTIV-8 childcare provision rules and policies.
Signed______Date ______