Registration Form/Booking Form - ASC

Registration Form/Booking Form - ASC

Please complete the following as fully as possible as applicable. There is a one-off charge of £30 when registering new children with extratime, payable on receipt of this completed form.

Which scheme would you like your child to attend (please tick one):

Woodingdean / Hillside, Portslade / St Luke’s, Brighton

The information you supply will be treated with absolute confidentiality.

Child’s name / Known as
DOB / Age
Address / Postcode
Home No / Mobile No
Email
School / Form / teacher
Hillside School pupils only: Community transport home? Yes No
Address where child is to be taken if different from home address
Name of parent carer at home address
Is this who will normally collect your child at the end of the session? / Yes No
If no, please give details of the person and their relationship to the child:
Name : / Relationship:
Address:
Contact No:
I consent for my child to go home unaccompanied: Yes No
Please name 2 other people who can be relied upon to pick-up your child should you be unable to do so. This should someone who we can contact between 4 – 5.30pm weekdays.
Name / Contact No/s
Address
Name / Contact No/s
Address
In the event of an emergency we may need to contact your child’s doctor.
Dr’s Name : / Tel No :
Surgery Name / address:
I consent to any emergency medical treatment necessary during the running of the club activities. I authorise staff to sign any written form of consent required by the hospital authorities if the delay in getting my signature is considered by the Doctor to endanger my child’s health and safety. Yes / No
Does your child have any known medical conditions or allergies? Yes No
If yes, please give details –
If you need to discuss the administration of medication whilst your child is in the care of the after-school club, please do so with the supervisor in detail. You will also need to complete a parental consent form for the administration of medicine.
Does your child have likes/ dislikes, any fears which we should know of in order to provide sensitive care to his/her needs? Yes No
If yes, please give details –
.
Please tell us anything else you feel is relevant to the care of your child during the after-school club session/s i.e. behaviour management programme, communication, issues eating/drinking/personal care etc.
Dependent on availability and current wait lists which days would you like your child to attend after school club:
Mon / Tues / Weds / Thurs / Fri

The staff at extratime are committed to ensuring your child is safe and happy whilst at the club. On occasion, it may be helpful for the supervisor to talk to your child’s teacher so that we can ensure we are fully able to meet all your child’s needs during their time with us.

Do you give consent for the supervisor to talk with your child’s teacher?

Yes / No

Additionally, it would be helpful to know about your child’s day at school when they come to the after-school club. For example, they may have been very tired, anxious or not drinking very well etc. Obviously this is particularly relevant where your child has very limited communication.

Do you give consent for the staff who are working with your child during that session to read your child’s home/school newsbook for that day?

Yes / No

All children attending the club who have communication difficulties will be able to take home a record of what they have been doing in that session along with any other relevant information. This will be recorded in their club/home newsbook.

Please indicate who the fees are to be paid by / All Social Services / All Parent Carer
Amount SS / Amount Parent Carer
If social services are contributing towards costs please detail:
Social Worker’s name / Contact No

Miscellaneous: I agree for my child to take part in local trips on the understanding that they will return by the end of the session YES / NO

Data Protection -extratime is registered under the 1998 Data Protection Act in respect of personal data that it holds. Some information written on this form is stored on a computer and in paper format for the purpose of assessing and monitoring the services extratime provides and who we provide a service to.

‘I understand that holding personal information relating to each child or young person isessentialfor the care and safeguarding of children and young peopleusing the projects.I understand that the information I providemay be shared with extratime employees and with other children's services with whom extratime works in partnership ona need to know basis.’

For more information please refer to extratime’s Data Protection Policy and Information Sharing Policy which are available in all the settings, and on the new web site -

Signature parent/carer

Print Name.

Date

Please return this form to;

extratime, Manor Offices Emmaus, Drove Road, Portslade, BN41 2PA

T: 01273 420580E: