Workshop Booking Form– Meath North (Kells) Workshop - Autumn Term 2017
Parent(s)/Guardian(s): ______
Address(es): ______
______
Mobile Phone: ______
Email Addresses: ______
DAIMembership Number: ______Membership of the DAI is compulsory for all families attending workshops.
First Child attending DAI Classes:
Child’s Name: ______Age: ______
Child’s Class/Year in school: ______
Second Child attending DAI Classes:
Child’s Name: ______Age: ______
Child’s Class/Year in school: ______
Third Child attending DAI Classes:
Child’s Name: ______Age: ______
Child’s Class/Year in school: ______
Parents should return this form to the Workshop Coordinator as soon as possible. If parents would like to make payments in advance, to spread the cost over the summer months, then payment options are set out below. Payments made over the summer will be reflected in the fee in the welcome letter you will receive at the start of the next term.
Credit or Debit Card:
Please phone our Branch Finance Administrator, Mary Scully, on083 876 3241 to pay by credit or debit card. Please give your child’s name and the Workshop they attend when paying.
Electronic Funds Transfer:
Please make sure that you put your child’s name as the payment reference so we know who the payment relates to. Bank Account Name: DAI Meath North IBAN:IE13AIBK93109808375668 BIC: AIBKIE2D
Cheque or Postal Order:
Please make these payable to ‘DAI Meath North’ and write your child’s name and the Branch name clearly on the back. These should be posted to: DAI, 5th Floor, Block B, Joyce’s Court, Talbot Street, Dublin D01 C861.
Emergency Contacts
Parents should sign their son/daughter in and out of the Workshop each evening. Workshop staff are not responsible for children on the premises outside the hours of the Workshop. Please provide the name and contact details of two people who may be contacted in the event of an illness or emergency during the hours of the Workshop.
Contact Person 1 ______Telephone: ______
Contact Person 2 ______Telephone: ______
Medical Information
Please detail any significant health issues your child has that it would be important for staff to be aware of?
______
______
______
______
Please give details if your child is currently taking any medication?
______
______
______
______
Name and Address of GP: ______
______
In the event of an emergency and when every effort has been made to contact me without success, I hereby give permission for my son/daughter to be taken to the surgery of the above named GP or taken by ambulance to hospital and there to receive any urgent medical/surgical attention deemed necessary in such an emergency.
I can confirm that all the information is accurate and understand that all this information is treated confidentially. Assessment reports are only shared with tutors on a need to know basis. Branch and Workshop records are maintained confidentially by the Dyslexia Association of Ireland at Branch and National level.
Signed: ______Date: ______
(Parent/Guardian)
Signed: ______Date: ______
(Parent/Guardian)
Booking Form for Meath North (Kells)Workshop – Autumn Term 2017