EmailMeForm
The Self Care Rebellion Registration Form
Please complete this form in full for each child attending, even if the details are similar.
Information for parents and carers
The Self Care Rebellion aims to provide a safe and enjoyable experience for every child or young person. To help us do this, please note the following important information.
• All questions on the consent form must be completed and signed by the parent or carer before any child takes part.
• Parents and carers must ensure they notify us of any changes to the information given on the form.
• Parents and carers must make arrangements for children to be brought to and from the activity safely and on time. If a parent or carer is not able to collect their child, they need to let us know in advance who will be doing so.
• We cannot take responsibility for any damaged clothing and/or personal items during the activity.
• Parents and carers should ensure children have sufficient water, clothing, sun lotion and medication (where appropriate) for the duration of the activity.
Which Course or Workshop will they be attending?
Child's Name
First
Last
Child's Date of birth
Parent or Guardian's Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
Email
Emergency Contact Second Option to Parent/Guardian Above
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
Email
Emergency Contact Third Option
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
Email
Child's Medical Details
GP Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
Email
Is there any extra help that your child may need?
Do we need to know about any medical conditions or allergies? (If yes, please provide details of the condition(s) and any medication needed).
Is there anything else you think we should know?
(Please only tick one box) On collecting my child I...
will be waiting outside the door and don't want my child to be allowed out of the premises at the end, unless I am present and in sight. If I tick this box I am also agreeing to ensure that the leader is told if anyone else is picking up my child
may be waiting in my car and am happy for my child to come and find me. I understand that once they leave the premises they are my responsibility, but that they have been asked to return to the premises if I am not waiting.
I understand that
*
the outdoor area/field/park are public spaces
snacks and drinks are sometimes provided
wide games that involve an option of being inside or outside such as hide and seek or sardines, rather than being inside or outside as a whole group may be played
in the case of an emergency, the emergency services will be called and first aid will be applied if deemed necessary by the leader
on most weeks, one adult will be running the group
the leader is not responsible for children before and after the times of their group
no conversation raised by the group will be halted but a parent will be contacted if the leader has any concerns
the confidentiality of members attending will be maintained unless the leader has any concern for the safety of welfare of that member or anyone else
activities may involve messy play like water, glue or mud
my child needs to bring a drink and appropriate clothing for indoors/outdoors
by signing this form I am agreeing to my child taking part in activities with The Self Care Rebellion
the Self Care Rebellion will keep a record of this form for health and safety reasons
that my child needs to behave with respect to fellow attendees and try to remain safe throughout the event.
I will be contacted by phone if my child is unhappy or needs me during the group and that if I am unavailable the emergency contacts will be contacted
Photography/Filming
I am happy for my child to be filmed (which may include voice) or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity.
I am happy for my child to be filmed (which may include voice) or photographed but do NOT want their face to be shown. This may be done through blurring the face or by ensuring the front of the face is not visible.
I do NOT want my child to be in any filming/photographs
Name
First
Last
Signature
Clear
Date Time
DD
/
MM
/
YYYY
