confidential data sheet
(Day Camp)
please use a separate form for each child Child’s Full Name Name “prefers to be called” Date of Birth Home Address
Postcode Home Telephone Number
(
)
Mobile Telephone Number (
)
Work Telephone Number
(
)
Mobile Telephone Number (
)
Work Telephone Number
)
Email Address Mother’s Name
Father’s Name
(
in the event of an emergency if we were unable to contact you on any of the above numbers an additional contact would be helpful Name Telephone Number
Relationship to Child (
)
please give us details of your child’s doctor Doctor’s Name Surgery Address
Surgery Telephone
(
) now, please turn over
Care Information give us details of any allergies, illness, special needs, dietary restrictions, etc or any other information that you think will make your child’s time at day camp as enjoyable as possible
Medication I will notify the Primary Crew Member of any specific medication that may need to be administered to my child, and understand that I will need to complete an additional consent form Permission for Emergency / Operative Treatment In an emergency it is sometimes necessary to obtain treatment for a child from a Doctor or a Casualty Department of a hospital. As a delay in these circumstances is highly undesirable, we would ask that you give your consent in case such an emergency should unfortunately arise and all efforts made to contact you have been unsuccessful Photography / Recording I understand that other parents are allowed to take photographs and record the play on the final afternoon for their own private and personal use I understand that if I take photographs or record the play on the final afternoon, that they are for my sole personal and private use and must not be used for any other purpose Plasters Sometime children have a bump or scrape that needs a plaster. We are not allowed to use these without your permission. In the event of sudden illness or accident affecting my child, if recommended by a Doctor, I agree to emergency treatment, including any operative treatment and / or administration of a general anaesthetic to my child (delete if you do not agree) I agree to my child being included in photographs / recordings taken by parents for their own personal use (delete if you do not agree)
I give my permission to use plasters I do not give my permission to use plasters Parent / Carer Signature Date The Man In The Moon : : 9 Beacon Hill Road : : HINDHEAD : : GU26 6NR Telephone / Fax: 01428 608866 : : www.themaninthemoon.co.uk
05/07