Child Information

If you are new or returning to Rebecca’s Out of School Club, we need you to complete this form.

Rebecca’s Out Of School Club Child Information Form

Please complete the secure online form below or download, complete and return to us the Word or PDF Child Information Forms

Child's name (required)

Name of the School the Child attends (required)

Which Out Of School Club would you like your child like to attend:

Parent/carer's name (required)

Mrs.Ms.Miss.Mr.Dr.

Parent/guardian/carer' Email address

Does this person have parental responsibility for the child? YesNo


Emergency Contact Information

Contact Name 1: (required) Mr.Mrs.Ms.Miss.

Relation to child:

Contact telephone number:

Address:

Postcode:

Contact Name 2: (required) Mr.Mrs.Ms.Miss.

Relation to child:

Contact telephone number:

Address:

Postcode:

Other information required

Allergies

Has your child ever had an allergic reaction to ANYTHING? YesNo
If yes, please provide full details:

Food/Drinks (especially fruit and snacks)

Please tells us about the child's likes, dislikes and any
special dietry requirements:

Activities

Please tells us what the child likes and dislikes doing and if there is
anything that they are scared of.

Language

Is English your child's second language? YesNo
If yes, please tell us the child's first language

Religion

What is the main religion of the family environment of the child?

Festivals

Are there any festivals or special occasions celebrated in your culture that your child will be taking part in and that you would like to see acknowledged and celebrated while he/she is in our care?

Health

Does your child have any of the following?:

Asthma/breathing problems YesNo

Skin conditions YesNo

Hearing difficulties YesNo

Sight difficulties YesNo

Speech difficulties YesNo

Any long term illness/conditions YesNo

If you have answered yes to any of the above, please give details below:

Name of doctor

Phone number

Address

Arrival/Departure

List the names of anyone (other than parents) who will be delivering/collecting your child.

Contact Name 1 (required) Mrs.Ms.Miss.Mr.Dr.

Relation to child

Contact telephone number:

Address

Postcode

Contact Name 2 (required) Mrs.Ms.Miss.Mr.Dr.

Relation to child

Contact telephone number:

Address

Postcode

Is there anyone who should not have contact with your child or is legally prevented?
YesNo.

If yes, please give details

Any other information

Is there anything else you think we should know in order to meet the needs of your child,
or anything you have concerns about?

Signature

Signature (Please type your name):

Date YYYY-MM-DD:

Rebeccas out of school club child information form
Rebeccas hout of school club child information form
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