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Registration Form

Please ensure you complete all sections of the Registration Form.
Submission of a booking form is not confirmation of a booking or guarantee of a space at club.
Please contact the Club via email at admin@115club.co.uk to ensure that there is space.
Please also note that a £20 annual registration fee is applicable to term time bookings.

 

How did you find out about the 115 Club?

Child's Surname:

First name:

Date of Birth:

Age:

Address:

Doctors Name and Address:

School Attended:

Class:

Mother's Name:

Address:

Home Telephone:

Mobile Telephone:

Email Address:

Work Address:

Work Telephone:

Father's Name:

Address:

Home Telephone:

Mobile Telephone:

Email Address:

Work Address:

Work Telephone:

Alternative Adult 1's Name:

Address:

Home Telephone:

Mobile Telephone:

Work Telephone:

Alternative Adult 2's Name:

Address:

Home Telephone:

Mobile Telephone:

Work Telephone:

Medical:

Personal, Social or Dietary:

Site:

Desired Start Date:

After School Club Days Required

Monday
Tuesday
Wednesday
Thursday
Friday

Breakfast Club Days Required

Monday
Tuesday
Wednesday
Thursday
Friday

Holiday Club Only

Holiday Club only

Method of Payment

Bank Transfer
Childcare Vouchers
Cash

I agree to the Club’s Terms & Conditions. (as found on our website and via link sent with every invoice). I also permit any member of the 115 Club Staff to obtain medical assistance either from my child’s doctor, the emergency services or hospital. (See SICKNESS, ACCIDENTS, FIRST AID AND EMERGENCY on Terms and Conditions.)

Signed:

Date:

Person with Parental Responsibility For: