PARENT/GUARDIAN MEMBERSHIP AND REGISTRATION DOCUMENT
To be held as an Official Record and used as Reference for Future events and General Information required by the Group
1. Name of Parent/Carer:
2. Home Address:
Post Code:
3. Contact Details: Home Tel.
Mobile Tel.
Work/ Other Tel.
Email Address.
4. Name of Child:
5. Diagnosis:
6. Date of Birth :
7. Address (if different to above) :
Post Code:
8.Medical information about your child:
a. Any conditions requiring medical treatment, including medication? YES/NO
If YES, please give brief details:
b. Please outline any special dietary requirements of your child and the type of pain/flu relief
medication your child may be given if necessary:
c. Is your son/daughter allergic to any medication? YES/NO
If YES, please specify:
.
I (parent/carer) accept sole responsibility to inform the Group of any changes in the medical information held and to do so in writing.
9. Declaration:
I agree to my son/daughter receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
I understand the extent and limitations of the insurance cover provided.
(A Parent/Guardian/Carer wishing to vary the terms of this 'declaration' must state their specific requirements for the attention of members and medical authorities, preferably also including the reason.
...
.
Signed:
..
Date:
..
Full name (capitals):
10. Emergency Contact:
1st Alternative emergency contact:
Name:
..
Telephone number:
.
Address:
..
.. Post Code:
2nd Alternative emergency contact:
Name:
..
Telephone number:
.
Address:
..
.. Post Code:
Name of family doctor:
Telephone number:
.
Address:
..
.. Post Code:
11. Photographs:
I agree to my child's photo being taken and used to promote the work of FOCAS in the following ways:
A: Actually taking photographs of my child Y/N
B. Using any photographs of my child within group only material e.g. newsletters Y/N
C. Using any photographs of my child within public material e.g. newspaper Y/N
D. Using any photographs of my child on the internet FOCAS website Y/N
12. Trip/Visits Consent:
I agree to
..taking part in any visit/trip based on the information provided by the group. I agree to him/her participating in the activities described and acknowledge the need for him/her to behave responsibly.
COPIES OF THIS FORM MUST BE TAKEN BY THE GROUP LEADER AND RETAINED AT BASE
Data Protection
FOCAS would like to continue to inform you of our progress and forthcoming events. If your personal details change, please help us to keep your information up to date by notifying us via A Richards at the details below. FOCAS complies with the Data Protection Act 1998 and all information provided to us will be treated in accordance with the act.
We will only use your personal information for internal administration purposes and to provide you with resources or information that you have requested. Please rest assured that we will not pass on or share your information with any other organization. If you prefer not to receive updates from FOCAS please contact A Richards Tel. 01287 633363 or email andrealrichards@aol.com.
Please could you fill 1 form per child per family. Thank you
Once the form has been printed and filled in PLEASE
return it by to Mr M Douglass
e-mail me for my address thank you
douglass_m@hotmail.com