Contact and Medical Form

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Email *

What is the name of your Child?

What is their date of birth? *

Does your child have any contact details? (Phone No, Email)

What School Does your Child Attend *

What is your name? *

What is your address? *

What is your email address? *

What is your phone number? *

Emergency contact numbers *

Does your son/daughter (a) have any conditions requiring medical treatment (e.g. asthma, diabetes, epilepsy etc.); (b) need to take any medication (e.g. Ritalin, inhaler, epi-pen etc.) or (c) have and needs with requirements to enable full participation in our programme of activities (e.g. wheelchair access, large print, learning difficulties etc.)? *

Can your son/daughter be responsible for taking their own medication? *

Yes

Does your son/daughter have any allergies (e.g. medication, foods, plasters, nuts, stings etc.)? *

Is there any other information that would be helpful for us to know about your son/daughter? (e.g. additional needs, special requirements)

Which town congregation do you attend?

I give permission for photographs/videos of my son/daughter to be used for Emmaus Rd/24-7 Prayer publications. *

Yes

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