Registration Form

Family Name: / School: Grange / Seaview
Child’s Name / DOB / Age / Class
Parent/Guardian’s Name:
Relationship to child :

MAIN CONTACT/ COLLECTION

Address:
E-Mail : / Telephone:
Home:
Work:
Mobile:

Will anybody else be collecting your child? Please provide details of other collection below. If a change of collection is to be carried out please notify the club in writing as we will refuse the collection if we are not aware prior to the change. If you fail to notify the club then you will be contacted on the above phone numbers.

Emergency Contacts / Collection:

Name: / Name:
Address: / Address:
Home:
Work:
Mobile: / Home:
Work:
Mobile:
Relationship to Child: / Relationship to Child:

PTO.

Medical Information: please ensure all areas are answered accurately.

Doctor’s Name:
Address:
Telephone Number:
Does your child have any medical problems which we should know about(asthma, allergies) YES/NO
If so please give details and also how you require us to deal with this i.e medication etc.
Does your child require any additional care? YES/NO
If so please give details:
Please tell us more about your child (e.g fears, dislikes, preferences etc):

Extra charges may be levied depending on level of care. If additional care is required assessment meeting must be held with the club manager prior to acceptance of registration.

If your child requires any medication, please inform a member of staff so that the appropriate documentation can be completed.

MOOSCC reserve the right to terminate membership without notice if inaccurate information is provided on the registration form.

MOOSCC logo was based on a design by Mya Bollan

I confirm the information is true and accurate.
Signed.______Parent/Guardian
Print Name: ______Date: ______
Can you please tell us where you received information relating to MOOSCC: i.e. friend/school etc?

Please return this form to: Monifieth out of School Care Club, at whichever site is more appropriate (addresses on the top right hand corner of this form).

Registration is renewed annually. Change of circumstances must be notified to the club manager immediately.

MOOSCC logo was based on a design by Mya Bollan