ZZZThe Kingswood School External Services (Terminated 26/10/2022) - Kingswood School

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KINGSWOOD BATH ACCOUNT CREATION FORM
This form is to be completed for everybody attending a course, holiday club or other event. If the person named is under 18, then the Parent or Guardian must sign the form. Please answer the following questions as fully as possible.

Todays Date:^*

Participants Forenames:^*

Participants Surname:^*

Address:^*

Postcode:^*

Home Telephone Number^*

Mobile Telephone Number^*

Email Address^*

Date of Birth of Attendee:^*

In an emergency you should contact the following person

Holiday Club and Sports Courses only

Name:

Relationship:

Address:

Postcode:

Contact Number

Daytime:

Evening:

Mobile:

Family Doctor's Name and address

Holiday Club and Sports Courses only

Name:

Practice:

Address:

Telephone:

Alternative emergency contact

Holiday Club and Sports Courses only

Name:

Relationship:

Address:

Postcode:

Contact number

Daytime:

Evening:

Mobile:

Medical Details

Holiday Club and Sports Courses only

Any known infectious diseases with which your child(named above) has been in contact within the last three weeks?

(e.g. Chicken Pox, Diphtheria, Measles. Mumps, Rubella, Whooping Cough etc.)

Any known allergies / sensitivities / disabilities and details of any known precautions or remedies.

Details of any medicines / treatments currently being taken (including dosages) & the specialist / hospital concerned if appropriate.

(If you are requesting that a medicine is to be given, the bottles(s), or other items should be clearly labelled with your name and the exact dosages.)

Does the child named suffer from asthma, chest complaints, wheezing or hay fever, migraine fits or faints or any other illness or disability?

(If YES, please give details)

Date of last Tetanus injection

(if known)

The following medication will be available if required. Please indicate which may be used for your child.

(Please note that the contact above will be called before any medication is administered):

Calpol:

Yes
No

Wasp Ease or equivalent:

Yes
No

Any other treatment as deemed by First Aider:

Yes
No

Photographs and video images may be taken at our clubs, and these may include your child. The images may be used in the media, school website, or in other ways to premote KPS Active and Kingswood Prep School.

Please select YES in the box if you agree to the use of images that may include your child in these ways.

Yes
No

Can your child swim 5 metres unaided?

Yes
No

If no, an alternative activity will be provided for your child during the swimming session.

If yes, are you happy for your child to go Swimming?

Yes
No

Is there anyone else who may be collecting your child at the end of the day?

Children can ONLY be signed out by parents of the child or by people named above. If we do not recognise the person collecting the child, the contact above will be called to confirm the arrangements.

If it becomes necessary for my child to receive medical treatment and I cannot be contacted by telephone or any other means to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the organisers, to sign any document required by the hospital authorities.

Signed:

Name of Parent/ Guardian (print)^*

Relationship:^*

Date:^*

Email Address^*

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Confirm Email Address^*

Please confirm your email address to ensure it has been entered correctly.

Password

##########

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This challenge is to prevent automated systems from using this feature maliciously.
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