Child’s name: ………………………………………………………………
D.O.B: ……………………..
Parent/Carers name: …………………………………………………………….. (parent 1)
Parent/Carers name: …………………………………………………………….. (parent 2)
Address: ……………………………………………………………………………………….
……………………………………………………………………………………………………….
Home phone number: …………………………………………………………………
Mobile number: …………………………………………………………………………..
Email address: ……………………………………………………………………………..
Doctor: ………………………………………………………………. Telephone: ……………………….
| MON | TUES | WED | THURS | FRI | FULL TIME |
Date to start: ………………………………..
DECLARATION: I have read the terms and conditions of the booking contract and agree to abide by them: ………………………………………………….