Booking Form

Booking Form

Booking form incorporating the Health & Safety questionnaire
 
Dates of course for which applied:
Course venue:
Course times:
Course cost:
Name of Parent/Guardian:
Address:
Postcode:
Telephone (home):
Telephone (work):
Mobile:
Email:
 
If you cannot supply a telephone number, please arrange an alternate contact number
Contact name: not required
Day contact number: not required
 
Your childs details:
Child's firstname:
Child's surname:
Date of birth:
Age:
 
Please state your child's level of ability:
 
Health & Safety Questionnaire (to be read and completed by parent/guardian)
1) Date of child’s last Tetanus injection.
2) Has your child had a recent injury or illness? If yes, give details.
3) Is your child at present under any treatment for any condition? If yes, give details.
4. Has your child any allergies? If yes, give details.
5. Please state any medication (type and dosage) which is required by your child and be sure they have it with them.
6. Has your child been given specific medical advice to follow in emergencies (eg use of inhaler, insulin injections etc). Please give details.
7. Please detail below any condition from which your child suffers.
Asthma or bronchitis: If yes give details  
Heart condition: If yes give details  
Fits, fainting and blackouts: If yes give details  
Servere headaches: If yes give details  
Regular medication: If yes give details  
Allergy to any know medication: If yes give details  
Other allergies, e.g. food, plasters: If yes give details  
Other illness or disability: If yes give details  
Diabetes: If yes give details  
Physical weakness: If yes give details  
 
Your doctor details
Name of family doctor:
Address:
Telephone:
 
I give permission to administer the following commercially available medicines:
Pain-relieving sprays eg PR Heat, PR Freeze, Wasp-eze: Yes No
Paracetamol: Yes No
Cough/sore throat ‘sweet’ e.g. Strepcils: Yes No
Bonjela mouth gel: Yes No
Antiseptic creams and ointments eg Dettol, Savlon, TCP: Yes No
 
PARENTAL CONSENT AGREEMENT - Please read carefully and check the agrrement box at the bottom of this page.

I hereby consent to the attendance of my child on the above Tennis Course when the person(s) in charge of the party of school children will be a member of the teaching staff and/or the Centre.

I further consent to the giving of such urgent medical or surgical treatment to my child as may prove necessary during the Tennis Course.

In consideration of the person in charge of the Tennis Course agreeing to the inclusion of my child as a member of the Tennis Course, I hereby undertake to indemnify him or her and any other member of the school course against any costs or expenses reasonably incurred by them on behalf of my child during the course, providing that such indemnity shall not extend to claims, damages or costs or expenses against the risk of which the person in charge of the school visit shall be indemnified under any policy of insurance.

It is important that the Course Leader knows if your child suffers even mildly from any medical conditions or is taking medication, so that extra care can be arranged, if necessary.

In the event of any illness or medical treatment occurring after the return of this form and prior to the activity, I undertake to inform the Course Leader.

I AGREE (please check this box)

 
(This will send your information to Acestars)