Fitzwilliam Explorer Activity Form

Information and consent form please complete legibly in black ink and please return the lower
section of this form, completed and signed, to the Activity Leader by:- 6:30 20/11/10

Activity Date: - 20/11/10 Transport provided from and to the scout hut

Additional information: - Additional money for drinks and snacks if you want

Home contact: - Chris Moore Home contact phone: - 07881511550

Signed: - J Carter Leader’s Name: - James Carter Date: - 18/11/10

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Name of Section: - Fitzwilliam Explorers

Proposed Activity: - Bowling

On (date) 20/11/10 At (place) Carlton Bowling, Barnsley

Start time: - 6:30pm Finish time:- 8:30pm

Cost: - £6.50 per person for 2 games

Cheques payable to: - Fitzwilliam Explorers, Cash Only Please

Parents or Guardian’s consent, I have noted the arrangements and give permission for:-

(Name of child)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

To take part in (proposed activity):- _________________________________________

Please state if your child has a disability or condition which might be affected by this activity:-

_____________________________________________________________

_____________________________________________________________

Please indicate details of any medical treatment she/he is having at the moment:

_____________________________________________________________

_____________________________________________________________

I can provide transport (if yes please give details) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I can be contacted during the day on (Phone Number):- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date: - ____________________ I enclose fee of £

Signed: - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name: - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _