Registration and consent form

St John the Evangelist, Shirley

Growing Disciples

Child's Full Name *

First

Last

Date of birth

Full name of parent/guardian *

First

Last

Child's home address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Parent's/guardian's mobile phone number

Parent/guardian's e-mail address *

Family Doctor:

School and School year:

Does your child have any food allergies (please specify)?

Does your child have any medical conditions (please specify)?

Is you child on any medication (please specify)?

NHS number:

Details of last anti-tetanus injection:

Does you child have any special needs (please specify)?

Is there anything else you would like us to know about your child?

Alternative emergency telephone number:

Contact name and phone number of an alternative adult in case of emergencies:

Alternative adult's relationship to your child:

My child will be brought and collected from Growing Disciples

• Yes
• No

Please note that when Growing Disciples (Sunday School) are meeting during a church service, they will be taken out of church by their leaders at the beginning of the service and brought back into church towards the end of the service.

My child will be collected by:

Relationship to child:

Name of anyone NOT allowed to collect my child:

If you have any concerns about the above, please inform the Parish Safeguarding Officer

My child has permission to travel to and from Growing Disciples without me (children over 11 years)

• Yes
• No

In an emergency and/or if I am not contactable, I am willing for my child to receive medical or dental treatment including anaesthetic

• Yes
• No

I give permission for my child to attend Growing Disciples and take part in activities.

Submit

Your privacy is important to us and we are committed to keeping your personal information confidential and secure. For more information on how we process your data, please see our privacy notice which is available on our website and church noticeboard.