Registration Form

Child's First name

Child's Last name

Child's Date of Birth

Day

Month

Year

Child's Age

School Child Currently Attends

Parent/Guardian's Full Name

Parent/Guardian's Email Address

Address

Emergency Contact's Name

Emergency Contact's Phone Number

Second Emergency Contact's Name

Second Emergency Contact's Phone Number

Medical Information Please list any medical conditions, medications or special needs that we should be aware of:

Dietary Requirements Please specify any dietary requirements, allergies or food restrictions:

Please list any interests or hobbies your child has, so that we can make their time extra special!

We will occasionally take photos and videos during our programmes for promotional purposes. Please indicate your consent for your child's photos and videos to be used on our social media platforms and promotional material.

I give permission for my child's photographs/videos to be used.

I do not give permission for my child's photographs/videos to be used.

Is there anything else we should know to ensure your child has the best experience possible?

I, the undersigned, confirm that the information provided is accurate and complete. I give permission for my child to participate in the Little Leap Frogs holiday camp.

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Date

Day

Month

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