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Starter pack 2012 Starter pack 2012 Document Transcript

  • STARTER PACK Contents: Membership Application Form Booking Information Form Allergy Information Form Local Activity Consent Form Medical Information/Consent Form Photography Consent FormLochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012
  • c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DG MEMBERSHIP APPLICATIONName of Family _______________________________________________Name of child(ren) (1) _________________________________ DoB _____________________________ (2) _________________________________ DoB _____________________________ (3) _________________________________ DoB _____________________________I WOULD LIKE TO ENROL THE ABOVE NAMED CHILD(REN) WITH LOCHWINNOCH OUT OF SCHOOL CLUBI understand that my membership is valid from ______________________ until one month’s written notice of cancellation isreceived by the Club. I enclose a one off registration fee of £10 (Cheques payable to LOSC) Parent signature Please print name Address Telephone number E-mail Address Date Payment Agreement • I understand that I will be invoiced monthly for all the childcare that I have booked if my child attends the Club or not. • I understand that one month’s notice must be given when cancelling of my child’s space or altering booked sessions. • I understand that bills must be paid by the date stated on the invoice or may be subject to a late payment feeI agree to comply with the aboveSigned___________________________________________ Date ________________________------------------------------------------------------------------------------------------------------------------------------------------- This section will be completed by LOSC and returned to you Certificate of MembershipThis is to certify that the undernoted child(ren) has been enrolled in Lochwinnoch out of School ClubManager’s Signature:Telephone Number: 07757 801042Date: Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012
  • c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DG BOOKING INFORMATION FORMName of Child(ren)SchoolClass/esName/Address and Telephone Number of Parent/GuardianNameAddressTelephoneE-mailDoes your child have additional support needs Yes / No If yes please specify requirements PLEASE TICK DAYS AND TIMES REQUIRED Day Breakfast 3-5pm 3-6pm 4-5pm (S1/2) 4-6pm (S1/2) Monday Tuesday Wednesday Thursday Friday The forms in this pack, together with your membership fee should be returned to: Lochwinnoch Out of School Club c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DG Tel: 07757 801042 We will advise you as soon as possible if we are able to offer your child a place at the Club Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012
  • c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DG ALLERGY INFORMATION FORMNAME ______________________________________________ DoB _______________________ADDRESS______________________________________________________________________________________________________________________________________________________________ALLERGY _______________________________________________________________________SYMPTOMS (Please describe in detail all the signs and symptoms your child may experience)TREATMENT AUTHORISED (Parents must complete medication form if applicable)GP DETAILSName __________________________________________________ Phone Number ______________________Address _____________________________________________________________________________________Signature of Parent ________________________________ (consent to medication when required) Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012
  • c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DG LOCAL ACTIVITIES CONSENT FORMAs part of the LOSC responsibility for the health and safety of participants in approved activities, it is important thatthe Play Leader be aware of any medical conditions your child has. Completion of this form is therefore arequirement for all children participating in specified LOSC activities.Name of Child _______________________________________________________ DoB _________________Address_________________________________________________________________________Home Tel No _____________________________ Mobile Tel No ___________________________ 1) Emergency Contact Name ____________________________________ Relationship to child: __________________________ Phone: _________________________ 2) Emergency Contact Name ____________________________________ Relationship to child: __________________________ Phone: _________________________ 3) Emergency Contact Name ____________________________________ Relationship to child: __________________________ Phone: _________________________Name & Address of GP: _____________________________________________________________Tel No: ____________________________________ Authorised Collection from Club:Name ________________________________ Name ___________________________________Relationship to Child ____________________ Relationship to Child _______________________I agree to my child participating in activities in and around Lochwinnoch such as visits to playgrounds, Library,RSPB, Castle Semple Centre and supervised outdoor activities eg. football, rounders. Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012
  • c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DG MEDICAL INFORMATION/CONSENT1) Does your son/daughter suffer from any medical condition that could require expert medical attention? YES/NO (If the answer is YES please provide further details)________________________________________________________________________________________________________________________________________________________________________2) Does your son/daughter have any allergies or reactions to drugs (this includes natural therapies)? YES/ NO (If the answer is YES please provide further details including reactions, treatment requirements etc. You may be asked to discuss this condition in detail with the Play Leader/Manager)__________________________________________________________________________________________________________________________________________________________________________________________3) Does your son/daughter have any special dietary requirements? YES/NO (Details if applicable)__________________________________________________________________________________________________________________________________________________________________________________________5) Does your son/daughter have any special needs (eg. wheelchair)? YES/NO __________________________________________________________________________________________6) Date of last tetanus toxoid booster (immunisation is voluntary)? ____________________7) Are there any other matters or circumstances that will/could affect your son/daughter’s participation in an activity?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012
  • c/o Lochwinnoch Primary School Calder Street, Lochwinnoch PA12 4DGI, _________________________________________________ being parent/guardian of the above named childhereby give permission for the LOSC Staff to give the immediate necessary authority on my behalf for any medicalor surgical treatment recommended by competent medical authorities, where it would be contrary to my son/daughter’s interest, in the doctor’s medical opinion, for any delay to be incurred by seeking my personal consent.I declare that the answers to the above questions are true, that I have not withheld any relevant informationSigned ______________________________________ Date: ______________________________ PHOTOGRAPHY/VIDEO CONSENTDuring the sessions, photographs and videos may be taken of your child for example on outings, outdoor play etc.These photographs are displayed for parents and visitors and may also be used on Lochwinnoch Out of SchoolClub’s website (www.lochwinnochoutofschoolclub.co.uk)I *give/do not give permission for my child to be photographed/videoedSigned ______________________________________ Date: ______________________________*Delete as appropriate Information on this form will remain confidential to the Play Leader, and associated administrative support personnel Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990 Starter Pack Revised June 2012