REGISTRATION FORM ActionPak 2010

NB: All telephone numbers completed below to not have any gaps please.
* denotes required field

Child's full name*:
Date of birth*:
Age:
Sex of child*:	Male Female
Home address*: (please include postcode)
Home tel*:
Ethnic Religion:
Parents' Email:
Mother's name*:
Place of work:
Work tel:
Mobile
Father's name*:
Place of work:
Work tel:
Mobile
3rd emergency contact*:
Tel*:
4th emergency contact:
Tel:

Child's Doctor*:
Address*: (please include postcode)
Tel*:
Known Allergies:
Other information we should know about your child:
Please indicate how you heard about ActionPak:

Preferred Group:

4-5 5-6 6-7 8-9 9-10 11-14

Please tick all dates to be attended:

Easter March/April 2010
Mon 29th		Tues 30th		Wed 31st		Thur 1st		Fri
Mon		Tues 6th		Wed 7th		Thur 8th		Fri 9th

Summer July 2010
Mon 19th		Tues 20th		Wed 21st		Thur 22nd		Fri 23rd
Mon 26th		Tues 27th		Wed 28th		Thur 29th		Fri 30th

Summer August 2010
Mon 2nd		Tues 3rd		Wed 4th		Thur 5th		Fri 6th
Mon 9th		Tues 10th		Wed 11th		Thur 12th		Fri 13th
Mon 16th		Tues 17th		Wed 18th		Thur 19th		Fri 20th
Mon 23rd		Tues 24th		Wed 25th		Thur 26th		Fri 27th

Siblings attending on the same day will both be charged £23 per day

No. of days booked @ £28 per day Total £

No. of days booked @ £23 sibling rate Total £

No. of Horse Riding sessions at £15.50 per session Total £

(optional – places may be limited)

Swimming
Can your child swim unaided at least 20m without armbands?			Yes No
Please give information regarding your child’s swimming ability:

None	Limited	Intermediate	Confident	Very Confident

Persons permitted to collect my child*:

Non attendance will be charged at full daily rate. Cancellations/changes to bookings cannot be made once ActionPak starts. Additional days may be booked subject to availability.
Payments must be made 14 days in advance Please make cheques payable to Acorns Nurseries Limited
We occasionally require photography for future publicity materials. If you DO NOT wish your child to appear in these photos please tick here
I hereby give my consent for the above named child to take part in swimming, sports activities and trips to various destinations as part of ActionPak.
Agree Disagree
I also give my consent to allow any Medical Attention that my child may require.
Agree Disagree
Relationship to child*:
Today's Date:
Form Completed By:	(Parent/Guardian)