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The Self Care Rebellion Registration Form
Please complete this form in full for each child attending, even if the details are similar.
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?
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.
I agree
to my child taking part in activities with The Self Care Rebellion
to the Self Care Rebellion keeping a record of this form for health and safety reasons
to any medical treatment that my child may need being given in an emergency
to my child being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity.
that my child needs to behave with respect to fellow attendees and try to remain safe throughout the event.
Name
First
Last
Signature
Clear
Date Time
DD
/
MM
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YYYY
