APPLICATION FORM – CHILD

First name of child

Last name of child

Child's gender

Home address

Email address of parent/guardian

Phone number of parent/guardian

Emergency backup phone number

Child's date of birth

School year

Child's school

Which location are you applying for?

As far as you are aware, does your child have any allergies?

Yes

No

Child's allergies

Is your child taking any regular medication?

Yes

No

Medication

Please give us any information regarding your child’s health, behaviour, communication, mobility, schooling and any other issues which help us meet their needs whilst attending The Habbit Factory. If necessary, please supply a care plan.

Do you grant The Habbit Factory the absolute right to use the images resulting from photo / film shoots. This includes any reproductions or adaptations of the images for all general publicity purposes?

Yes

No

First name of child's parent/guardian/carer

Last name of child's parent/guardian/carer

Next of Kin's name / how they wish to be referred to

Next of Kin's relationship to child

Application approved by child’s parent/guardian/carer

I have read, understood and accept the Terms(Terms)

Your Signature

Date of application

How did you hear about us?

What do you/your child hope to gain from joining?