Personal Details

Child's Full Name

Emergency Contact

Name of Parent/Guardian

Email Address

Address

Phone Number

Relationship

Medical Details

Is the child on any medication?
 Yes No

If necessary, please provide details:

Does the child suffer from allergies?
 Yes No

If Yes, please provide details:

Has your child been immunized against tetanus?
 Yes No

Does the child have a history of illness/injury that may be aggravated by activity?

Are there any medical, psychological or physical conditions we should be aware of that will require special attention?

Are there any special dietary requirements that we should be aware of?

Children will have the opportunity to swim in a chlorine swimming pool. An adult will be present at all times whilst children are swimming. Please advise child's swimming ability/stage.

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