gLo has been initiated to allow young people to play a

positive role in their community.

Dates: Tues 12th Friday 15th August.
Meeting each morning @9:30am @
Emmanuel Church.
Cost: 25 includes T-shirts/lunch& supper.

APPLICATION FORM

Name: ______________________________

D.O.B._____________________

Address:___________________________________________________________
____________________________________________________________
Tel No:____________________________________________________________
Emergency Contact Details
Name:________________________________

Relationship:__________________

Daytime Contact No:_________________________________________________

Night Time Contact No:_______________________________________________
Medical
Dr. Name:__________________________________________________________
Dr. Address:________________________________________________________
Dr. Tel No:_________________________________________________________
Any medical conditions, allergies or medication we need to know about:
__________________________________________________________________
__________________________________________________________________
Any queries, please contact Grant 07763728962, Rick 07764342435 Nathan 07738583288
or Pete 07849576261
Under 18s please get parents permission and fill in the form below.
I give my permission for the above named to participate in the planned activities.
Signed:________________________
(Parent/Guardian)

Date:___________