Holiday Club Booking Form – Phoenix Youth and Community Centre

Please note

Confirmation of places and fees due will be provided by email after submitting this form.

Payments will then be required to confirm booking.

Once booked, fees are non-refundable, and dates cannot be altered.

ONLY DATES DISPLAYED BELOW ARE CURRENTLY AVAILABLE.

Parent / Carer's name (emergency contact 1) *

First

Last

Home address *

Post Code *

Contact phone number *

Email *

CHILD 1 – Name *

First

Last

CHILD 1 – Date of Birth *

CHILD 2 – Name

First

Last

CHILD 2 – Date of Birth

CHILD 3 – Name

First

Last

CHILD 3 – Date of Birth

WEEK: 22-26 JULY 2024 – please tick dates / times required:

Mon 22 Jul 2024 – half day (1pm-6pm)
Tues 23 Jul 2024 – half day (1pm-6pm)
Wed 24 Jul 2024 – half day (1pm-6pm)
Fri 26 Jul 2024 – full day (8am-6pm)
Fri 26 Jul 2024 – half day (8am-1pm)
Fri 26 Jul 2024 – half day (1pm-6pm)

WEEK: 5-9 AUGUST 2024 – please tick dates / times required:

Fri 9 Aug 2024 – half day (8am- 1pm)

WEEK: 12-16 AUGUST 2024 – please tick dates / times required:

Tue 13 Aug 2024 – full day (8am -6pm)
Thu 15 Aug 2024 – half day (1pm -6pm)
Fri 16 Aug 2024 – full day (8am-6pm)
Fri 16 Aug 2024 – half day (8am-1pm)
Fri 16 Aug 2024 – half day (1pm-6pm)

WEEK: 19-23 AUGUST 2024 – please tick dates / times required:

Fri 23 August 2024 – half day (1pm -6pm)

People authorised to collect your child/ren (as well as the main contact above) – Emergency Contact 2 *

First

Last

Emergency Contact 2 phone number *

Emergency Contact 2 email

People authorised to collect your child/ren (as well as the main contact above) – Emergency Contact 3 *

First

Last

Emergency Contact 3 phone number *

Emergency Contact 3 email

Is there anyone who is NOT allowed to collect your child (e.g. restricted by court order)?

School *

MEDICAL INFORMATION – Name of GP *

GP phone number *

Does your child have a medical condition we should be aware of? *

If yes, please give details.

Does your child have a physical or learning disability / difficulty? *

If yes, please give details.

Does your child take medication? *

If yes, please give name of medication, method of administration, dosage, times:

Does your child suffer from seizures *

If yes, please detail type of seizure (epilepsy or other), usual duration of seizure, who to contact / inform, special instructions:

Is your child neurodivergent? *

If yes, please give details e.g. ADHD / ASD / Social anxiety / Dyslexic / Dyspraxia / Other (please specify):

Is your child non-verbal? *

If yes, please give examples of any communication tools your child uses (e.g. pecs), if your child prefer to use a traffic light system for communication with staff / peers, give examples of any potential triggers for your child, give examples of any potential calming / soothing methods:

Would your child benefit from having a quiet space to go? *

If yes, please state to which child this applies (if applicable):

Does your child have a condition that effects their mobility? *

If yes, do they require any assistance? Please give advice on how to support your child physically, for example; reducing walking distances / times to enable them to participate or ensuring wheelchair accessibility to facilities:

Does your child require personal care support? *

If yes, please provide details:

Does your child have any special dietary requirements? *

If yes, please provide details:

Does your child have any allergies or food intolerances? *

If yes, please provide details:

Does your child have any specific fears, phobias or anxieties? *

If yes, please provide details:

CONSENT FORM – I hereby give permission for the following: *

1) ACCIDENTS – If my child requires emergency treatment and I am unable to be contacted, I give my consent for any essential treatment to be given in my absence by the appropriate persons. *

I consent

(2) ADMINISTERING MEDICATION – I understand that no medicines will be given for which I have not given written instructions, but, where instructed, I give my consent for prescribed medication to be given to my child by the Phoenix Play Scheme Supervisor, in my absence. *

I consent

(3) OUTDOOR ACTIVITIES IN THE PARK (wearing high visibility tabards) – I give my permission for my child to play outside the centre, using risk-assessed and supervised facilities in the park, such as the play area, the ball zone, the tennis courts, and coned-areas on the field. *

I consent

(4) APPLICATION OF SUN-BLOCK CREAM – I give my consent for the administration of my child’s own sun block cream, if s/he requires assistance. *

I consent

(5) PHOTOGRAPHS – I give permission for my child to be photographed by the Phoenix Play scheme staff, as a record of activities. (Please note: any photos used on our website or social media will not contain facial images, we solely aim to focus on the activity as a form of documentation). *