ROCKY’S PLAICE REGISTRATION/CONSENT FORM – please use this form to book a place for your child.  A separate form must be used for each child or you can register on-line and this will be acknowledged by e-mail..  This form can be photocopied or further copies are available for download at www.knaresboroughurc.org
 
Rocky’s Plaice  will take place at Knaresborough United Reformed Church, Gracious Street, Knaresborough from
Monday 27 July to Friday 31 July.   
10.00-12.00 noon – children who have completed school years:  Reception, Year 1, or Year 2
1.30-3.30pm – children who have completed Year 3, Year 4, Year 5 or Year 6
Please join us for a special holiday club ‘launch' at 10.00am on Sunday 26 July.

Child’s full name                                                                                                                       Sex:  M / F

Date of birth                                    School

Please register my child for Rocky’s Plaice

Parent’s/Guardian’s signature     

Parent’s/Guardian’s full name

Address                                                                            E-mail address (used only for acknowledgement)

Telephone Number
                                                           
Emergency contact name                                                 Phone Number

GP’s name                                                                       GP’s Phone Number

NHS number                                                                    Date of last anti-tetanus injection

Any known allergies or conditions

I confirm the above details are complete and correct to the best of my knowledge.
In the unlikely event of illness or accident I give permission for any necessary medical treatment to be given by the nominated
first-aider.  In an emergency and if I cannot be contacted, I am willing for my child to receive hospital treatment, including anaesthetic if necessary.  I understand that every effort will be made to contact me as soon as possible.

I give permission for my child’s image to be taken and used on the URC website /magazine/local press         Yes / No

Parent’s/Guardian’s signature                                                                 Date

Please return completed form to Knaresborough United Reformed Church, Gracious Street, Knaresborough HG5 8DT