Parent Email Address: (required)

Child/young person name: (required)

Address: (required)

Postcode: (required)

GP Name: (required)

GP Address: (required)

Parent/Carer mobile Telephone number: (required)

Second Emergency Contact Telephone number: (required)

Date of Birth: (required)

What school does your child or young person attend: (required)

What school/college/training or volunteering setting do you attend?

Does you child or young person attend any community activities?

Does you child or young person access any community activites please record?
SportsArt SessionAt HomeOutdoor ActivityOther

Does your child or young person have a disability or additional need?
if yes please state:

Does your child or young person have any allergies if yes?
please state and record any medication prescribed:

Does your child or young person have any allergies if yes?
please state and record any medication prescribed: (required)

To comply with the Data Protection Act 2018, Athac needs your permission before we can photograph or make any recording for promotional purposes.
Consent to the image or social media use can be withdrawn at anytime by informing Athac CIC
Yes I consent to photographs being taken.No, I do not consent to photographs.Yes, I give consent to use of images on social media.No, I do not give consent to social media.No, I don't give consent to photographs and social media.

Print Name: (required)

Today's Date: (required)

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