Address______________________________________________________________
_____________________________________________________________________
DOB________________________________________________________________
Telephone Number____________________________________________________
Telephone Number_________________ Telephone Number__________________
Medical Information: (Please state any medical conditions, including support required, and medication requirements. This section must be completed before an application can be considered)
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Doctor: ______________________________Tel no.:________________________________
Medical Practice ____________________________________________________________
Other Information: (please provide any other information that we may need to know about you)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Who will be collecting you from the Club?
Name:________________________ Name: _____________________________________
Relationship: __________________ Relationship: _______________________________
Contact no.: __________________ Contact no.: _______________________________
Social Worker
Name: ________________________ TEL Number: ______________________________
Address: _________________________________________________________________
My son/ daughter is under the age of 16 years old. I here by give my consent for them to attend the Pennypit Special Needs Youth Club
Signed: __________________________________
Relationship: __________________________________
Date: __________________________________