Holiday Club Booking Form

Please only complete this form if your holiday club place has been booked and confirmed.

Please complete all sections so we can make sure your child has a safe and enjoyable time at Little Village Wellbeing Holiday Club.

Booking Details

Which session are you booking?

Which day?

Date of session

Child’s Details

Child’s Full Name Date of Birth Age Home Address Postcode

Parent / Carer Details

Parent / Carer Name Relationship to Child Mobile Number Email Address

Emergency Contact 1

Name Relationship to Child Telephone Number

Emergency Contact 2

Name Relationship to Child Telephone Number

Collection Arrangements

People authorised to collect your child I have read and understand the collection arrangements.

Medical Information

Does your child have any medical conditions? Medical condition details Is your child taking any medication? Include EPIPEN, diabetes monitoring, inhalers and dosages. Medication details Does your child have any allergies? Allergy details Does your child have any SEND, communication, behavioural or sensory needs? Additional needs details GP Surgery Optional

First Aid & Emergency Consent

Has your child previously worn adhesive plasters without a reaction? If no, please provide details I give permission for trained staff to administer basic first aid. In an emergency, if I cannot be contacted, I give permission for staff to seek emergency medical treatment.

Activity Consent

Face Painting Glitter Tattoos Messy Play I understand Little Village Wellbeing cannot accept responsibility for staining or damage to clothing.

Water Bottle

Water bottle option

Policies

I have read and understand the food policy. I have read and understand the illness policy. I have read and understand the behaviour expectations.

Photography & Video Consent

Please select one option

GDPR & Privacy Notice

I have read and understand the Privacy Notice.

Parent / Carer Declaration

I confirm the information provided is accurate and complete, and I agree to the policies and consents selected. Parent / Carer Name Typed Signature Date

Your information will only be used to manage your booking and help keep your child safe during the session.