Genius SP Registration Form

Genius Specialist Registration Form

Section1: Contact Details

Child's Full Name

Date of Birth

Gender

Nursery/School/College attending

School Year

Address

Is address confidential?

Yes

Parent/Carer Details

Parent First name

Parent Last name

Relationship to Child

Phone

I receive income related benefits

Yes

I receive/eligible for Income Related free school meals?

Yes

If you are picking up your child at the end of the holiday club please provide details of adult(s) collecting your child.

Details of Adults Collecting

Section 2: Emergency Contact Details

In the event of an emergency we aim to contact the Parent/Carer names in the Section 1: Contact Details. Please provide details for at least one other contact who is NOT the same as the parent/carer

Emergency Contact Full Name

Emergency Contact Number

Emergency Contact Relationship

Section 3: Medical Information

The Specialist Play Scheme has access to medical information about your child, held on local social care and education systems.

What GP/Doctor's Practice is your child registered with?

GP Name (optional)

GP Telephone

GP Address

Current Medication

Is your child receiving any medication?

Yes

Medication and Frequency

Will your child need their medication to be administered at the playscheme?

Yes

Section 4: Allergies/Dietary Needs

Does your child have any allergies or special dietary requirements?

Yes

If yes, please provide details below:

Section 5: Feeding

The play scheme has access to your child's feeding profile if they have one. Please tell us about any additional feeding requirements your child may have such as supplements or equipment.

Does child have any feeding requirements?

Yes

If yes, please provide further information below:

Section 6: Communication

How does your child communicate?

If they have specialist communication equipment, will this be available to use during activities?

Yes

Section 7: Personal Care

Does child have any personal care needs?

Yes

If yes, please provide details including any required equipment.

Is any equipment needed to support this?

Yes

Please ensure you send adequate supply with your child

Section 8: All About Me

Things I like...

Things I do NOT like...

Please detail any other information you feel we should be aware of:

Add your text

Section 9: Consent

Please tick YES or NO to the following statements:

I agree to my child being given basic first aid by a trained first aider.

I agree that my child requires support with applying sun lotion.

In the event of an emergency, I agree to my child being given treatment by a qualified medical or dental practitioner.

I agree to use of my child’s name and photo in newsletters, websites, or social media.

I understand that this material may appear in public areas; some or all of this information may be used by the Genius Tuition in the course of their business (advertising / publicity) and my consent is conditional upon compliance with the their obligations under the law including the General Data Protection Regulation; where the image is used on the internet or social media

I understand that where the image is used digitally e.g. posted on the internet, that Genius Tuition may not be able to remove all copies of the images from the internet

I consent to Genius Tuition sharing relevant information related to this application with schools and local councils, where necessary, to support the delivery of services and maintain safeguarding and administrative standards.

Parent/Carer Signed:

Parent/Carer Full Name:

Date Signed:

03303 110 860

info@geniustuition.co.uk

Genius Specialist Registration Form