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Little Explorers

Play and Discover – Out of School Club

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NB. We shall treat this information with the strictest confidentiality and in accordance with data protection guidelines.

Little Explorers NI - Registration Form

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Child's Legal Name *

Child's Preferred Name

Date of Birth *

School Attended

Class 2016/2017

Monday Clubs *

None
Breakfast Club
Afternoon Club
Both

Tuesday Clubs *

None
Breakfast Club
Afternoon Club
Both

Wednesday Clubs *

None
Breakfast Club
Afternoon Club
Both

Thursday Clubs *

None
Breakfast Club
Afternoon Club
Both

Friday Clubs *

None
Breakfast Club
Afternoon Club
Both

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Relationship to Child *

Address 1 *

Address 2

Town/City *

Post Code *

Parent/Guardian 1 Email *

Parent/Guardian 1 Phone

Parent/Guardian 1 Mobile *

Parent/Guardian 1 Work Phone

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Relationship to Child

Address 1

Address 2

Town/City

Post Code

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

Parent/Guardian 2 Mobile

Parent/Guardian 2 Work Phone

Authorised to Collect 1: First Name

Authorised to Collect 1:Last Name

Authorised to Collect 1: Date of Birth (security)

Authorised to Collect 1: Relationship

Authorised to Collect 1: Phone/Mobile

Authorised to Collect 2: First Name

Authorised to Collect 2: Last Name

Authorised to Collect 2: Date of Birth (security)

Authorised to Collect 2: Relationship

Authorised to Collect 2: Phone/Mobile

Authorised to Collect 3: First Name

Authorised to Collect 3: Last Name

Authorised to Collect 3: Date of Birth (security)

Authorised to Collect 3: Relationship

Authorised to Collect 3: Phone/Mobile

Doctors : Name *

Surgery Phone *

Surgery Name and Address *

Immunisation (Tick all that child has received)

Diptheria/Tetanus/Whooping Cough
Polio
Measles/Mumps/Rubella
Pre-School booster
HIB/Meningitis C

Does your child or has your child suffered from any serious medical conditions?

Does your child attend hospital for any reason?

Does your child regularly take medication for any reason?

Does your child have special dietary requirements?

Does your child suffer from any allergies?

Does your child have problems with sight/hearing/speech or other physical issues?

Any other medical information that is relevant?

Do you consent for your child to be transported to hospital by a member of our staff in the event of an emergency? *

YES
NO

What is 13 minus 6 ? Please input number not word. *

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