Full Name of Child/Adult:

    Full Address:

    Phone Number:

    Email:

    Date of Birth:

    Preferred Method of Communication:

    Name of Parent/Carer:

    Full Address: (If Different From Above)

    Phone Number: (If Different From Above)

    Email: (If Different From Above)

    Any medical conditions?
    YesNo

    If yes please give details:

    Details of medication required: (eg inhaler)

    Any dietary requirements?
    YesNo

    If yes please give details:

    Additional Information:

    The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial long-term adverse effect on his or her ability to carry out normal day-to-day activities’.

    Do you consider yourself to have a disability?
    YesNo

    If yes, what is the nature of your disability?

    Emergency contact details - Please insert the information below to indicate the person(s) who should be contacted in event of an incident/accident

    1st Emergency Contact Name:

    Relationship to Member:

    Emergency Contact Number:

    Emergency Contact Address:

    2nd Emergency Contact Name:

    Relationship to Member:

    Emergency Contact Number:

    Emergency Contact Address: