Child's Surname: Child's Forename:
Gender: MaleFemale Date of Birth: Day 12345678910111213141516171819202122232425262728293031 Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year 20062007200820092010201120122013
School Year (Academic year 2016/2017): ReceptionYear 1Year 2Year 3Year 4Year 5Year 6
Would your child like to be in the same group as a friend? YesNo If yes, please state their name:
Parent's Email Address:
Emergency Contact Details:
Please give details of anything we need to be aware of for
Medical conditions (include any medication):
I consent for medical treatment or first aid arising out of illness or accident. YesNo
I give permission for photographs and video of my child to be used in presentations of the holiday club, displays in the church buildings, or on the church website. YesNo
By submitting this form I give permission for my child to take part in holiday club activities at Cheam Baptist Church between the 29th August and the 1st September 2017.
Payment can be made by bank transfer to:
Sort Code: 20-84-17
Account number: 70246182
For a payment reference please use: HBC plus the Surname and Initial of the child. If you are paying for more than one child, please provide their name(s) and surname(s).
Please make cheques payable to Cheam Baptist Church and write the name(s) of the child(ren) on the back of the cheque and post to:
Dino-Snores Holiday Bible Club
Cheam Baptist Church
4 Park Road
Cheam, SM3 8QB.