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Wed, Feb 22, 2012
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Shine Activity Consent and Registration Form



I understand that:

My child will be engaged “risk assumed” activities under expert supervision such as BMX, Climbing Wall, Parkour, Archery etc.

Photographs and videos of children may be taken and used to showcase events

My child’s name will not be used on any publicity unless I authorise this.

That low level violence video games may be played

That my child may be asked to use an existing personal email account or be asked to create an email account to enable access and use of web tools for learning.

That my child may have outside activities within the boundaries of the venues used by Shine.

That my child may be under supervison, moved to other activity sites within the local area.

An incomplete form may mean your child will not be properly registered and may be refused to participate


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* Required information.
Shine Consent
Name * Name of person registering with Shine
Date of birth * Date of birth of person registering with Shine
Male or Female *
Male
Female
Which School do you attend * Which school is currently attended
Meden School & Technology College
Birklands Primary
Sherwood Junior
Cuckney Primary
Hetts Lane
Netherfield
Church Vale
Eastlands Junior
Other
Entitled to Free School meals *
Yes
No
School year *
Name of Parent/Carer/Guardian *
Relationship *
Parent
Carer
Guardian
Home Telephone Number *
Mobile Telephone Number *
Alternative Telephone Number This may be a work number or partners mobile
Address * Home address of person registering with Shine
Postcode * Home postcode of person registering with Shine
Email address
Preferred method of contact * How would you like Shine to contact you
Email
Text
Phone call
Name of authorised person allowed to collect your child * Name of persons authorised to collect you child from Shine sessions
Alternative Contact 1: Name *
Alternative Contact 1: Address
Alternative Contact 1: Phone number *
alternative Contact 2: Name *
Alternative Contact 2: Address
Alternative Contact 2: Phone number *
Do you give permission for photos to be used * Shine keeps a visual record of all activities, if you DO NOT want your child photos to be used please UNTICK the box
Doctors name
Doctors contact number
Medical Information List any allergies or issues we should be made aware of
By ticking this box you confirm that all details are correct and you give permission for your child to attend Shine sessions *
Yes
Todays Date *
Authorised by * Please give the name of parent/carer/guardian who gives permission