Summer holiday activity programme for SE and mid Northumberland. WEEK TWO

Holiday Card Registration Form For a free BVAL holiday card for your child please complete the registration form below and hand into reception at any BVAL centre. Once the form is completed you will be given a card which will enable your child to book onto all future holiday activities.

Name of child: ...................................................................

Male

Female

Contact Name ....................................................................

DOB: ........................................

AGE: .................

School Attending: ...................................................

Tel ..........................................................................

Emergency contact name and numbers ...............................................................................................................................

Email address .....................................................................................................................................................................

Address ................................................................................................................................. Postcode .............................

Does your child have any medical conditions/allergies?

Or take any medication which we should know about?

Yes

No

If yes, please specify ..........................................................................................................................................................

Do you consider your child to have a disability?

Yes

No

If yes, please give details ....................................................................................................................................................

Ethnic Origin (please circle the appropriate) White Asian-Pakistani

Black - Caribbean / African / Caribbean / UK / Other Asian-Bangladeshi Asian-Chinese

Asian-Indian Other (please specify)

Religion .................................... How did you find out about BVAL? ....................................................................................

I hereby give consent for my child to be given a BVAL holiday card which will enable my child to be able to attend future activities organised by BVAL. I will keep BVAL up to date with any changes to my child's details eg medical conditions etc.

I understand that while involved in the delivery of these activities personnel will take every reasonable precaution to ensure that accidents do not happen, they cannot be held responsible for any loss, damage or injury suffered by my child.

I give my consent that in an emergency situation, BVAL may act in my place, (in loco parentis), if the need arises for the administration of emergency first aid and / or other medical treatment which in the opinion of a qualified medical practitioner may be necessary. I also understand that in such an occurrence all reasonable steps will be taken to contact me as the relevant parent / legal guardian.

I am aware that during activities photographs and videos may be taken for promotional use (including the internet) by BVAL and agencies working in partnership with BVAL (If not in agreement please enclose a letter stating this).

In accordance with the Data Protection Act 1998 the information you give us will be held on our database for the purpose of supplying you with information regarding future activities and for monitoring your attendance and evaluating the programme.

If you do not wish to receive this information please tick this box

Signed ......................................................................... Parent/Guardian/Carer

Date .....................................................

18 | www.bval.co.uk - 01670 542222