1

Styx summer play scheme 2014

Young person information

Full name of Child:___________________________________________________________________

Gender (circle):
DOB:

Male

Female

______________/______________/________________

School attending: ___________________________________________________________________

Year at school (circle):

Family Doctor: ________________________ Practice:_____________________________________

Are there any relevant illnesses, allergies or regular medication staff should be made aware about?
Please give details if so: ______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Below are details for 2 emergency contacts, 2 emergency contacts MUST be given
Emergency contact 1:_________________________________________________________________
Relationship to child__________________________________________________________________
Telephone number (home)_____________________________________________________________
Telephone number (mobile)____________________________________________________________
Telephone number (work)______________________________________________________________

Emergency Contact 1:_________________________________________________________________

Relationship to child__________________________________________________________________
Telephone number (home)_____________________________________________________________
Telephone number (mobile)____________________________________________________________
Telephone number (work)______________________________________________________________

I give permission for my childs photo to be taken and used in any future promotional activities (Circle)

Yes

No

I know all details given above are true and give permission for the child mentioned above to take part
in all onsite and offsite activities (for any offsite activities you will be given specific information prior
to the event). I also give permission to the trained and qualified leaders to render First Aid should the
need arise. I understand that despite extensive precautions taken, there is still a risk of injury or
property damage/loss through no fault of the staff unless there is a clear act of negligence and I
consent to the above named young persons participation with that knowledge.

Styxplayscheme

2
Signed_________________________________________
Full Name______________________________________
Relationship to child________________________________

Contact e-mail___________________________________________________________________

Name of young person_______________________________________________________________

Below please see all the dates that Styx summer play scheme will be operating in 2014.
For any dates you wish the young person mentioned above to attend, please circle.

Week

Monday

Tuesday

Wednesday

Thursday

Friday

28/07
04/08
11/08
18/08
25/08

29/07
05/08
12/08
19/08
26/08

30/07
06/08
13/08
20/08
27/08

31/07
07/08
14/08
21/08
28/08

01/08
08/08
15/08
22/08
29/08

2
3
4
5

The cost of each session is 10, so please include a cheque for the relevant amount, to be made
payable to Styx play scheme.
Address:
Richard Birnie
Western Parishes Youth & Community Centre
Longfrie
St Peters
Guernsey
GY7 9RZ
For peace of mind we will send a confirmation e-mail letting you know that your young person has
successfully been registered for all selected dates and that your permission form has arrived and all
details are satisfactory.

Styxplayscheme