Membership Form

Please complete the form below. We'll review your membership information and be in touch.

Club & child

Club Primary class (Aug 25 - Jun 26)

Child's name (in full) Sex

Date of birth Age

Address

Postcode School attending

School finish time

Parent/Guardian

At least one contact number across all parents/guardians is required.

Collection arrangements Password to be used when collecting child from club

Authorised collectors (in addition to parents/guardians)

Not authorised to collect (names/details)

Emergency contact (not a parent/guardian)

Name Relationship to child

Address

Postcode

Day telephone (incl. STD) Extension

Mobile Evening

Medical & additional information

Doctor’s name Doctor’s telephone (incl. STD)

Doctor’s address

Postcode

Known illnesses or allergies? Yes No

Special dietary requirements? Yes No

Regular medication? Yes No

Help needed administering prescribed medication? (Only medication prescribed by a doctor) Yes No

Particular or additional needs? Yes No

Statement on Additional Support for Learning (attach/copy if yes)? Yes No

Local Authority Children & Families / Social Work support (contact details) Activities your child should not take part in Games and activities your child enjoys

Attendance

Tick the days you would like your child to attend each club.

Breakfast Club (7.45 am – 9.00 am)

After School Club (3.00 pm – 6.00 pm)

Is this different from your child’s current attendance with us? Yes No

If joining during the school year, first day of attendance

For August registrations, places are reserved and fees apply from the first day of the school term.

Consent requests

Please read and choose Yes/No for each consent.

Excursions and short trips off premises (e.g. park, library, shops, walks) Yes No

Photographs taken at the club (displayed at club, not shared externally) Yes No

Photographs on Primary Playcare’s Facebook/Twitter/Webpage Yes No

Face/hand painting Yes No

Nail polish Yes No

Temporary tattoos/transfers (arms/legs/hands) Yes No

Emergency medical treatment if necessary Yes No

Authorise play staff to sign hospital consent in emergency if delay endangers child Yes No

Administer prescribed medication on parent instruction (additional paperwork required) Yes No

Monitoring information Ethnic group Any language spoken other than English

Payments via Childcare Vouchers? Yes No

Assistance from College/University with childcare costs? Yes No

Relevant information Anything else that would help us care for your child

Looking ahead (future siblings)

Priority is given to siblings of current service users. Add any future siblings below.

Terms & confirmation

If your application is accepted, this Membership Form forms the basis of your contract with the club. Four weeks’ notice (with full payment for those weeks) is required for permanent changes or to terminate your contract.

All information is handled in line with our confidentiality policy. See our Privacy Policy.

Printed name (parent/guardian)

Date

I have read the consent requests and marked them as appropriate, and I agree to the Terms & Conditions in the “How To Use Your Club” booklet.

Please wait while your form is processed.

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