Child's Full Name:

Child known as? (eg. Thomas/Tom)


Date of Birth: (eg. YYYY-MM-DD eg. 2010-04-18)


Current School Year Group:

Parent/Guardian's Full Name:


Your Email: (Used only for acknowledgement)

Telephone Number:

Emergency Contact Name and Number:

GP's Name and Number:

Any Known Allergies or Conditions:

In the unlikely event of illness or accident, I give permission for any necessary medical treatment to be given to 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;

Do you give permission for your child's photograph to be taken and used on the URC website/magazine:

Do you confirm the above details are complete and correct to the best of your knowledge:

We would like to update you by e-mail with children's events at KURC. Your details will be held securely and they will never be pasted to a third party, sold or shared. You can withdraw your consent at anytime by contacting the Church Secretary via Do you consent to us using your details in this way?: