Senior Programme College Participation Form PLEASE USE BLACK INK AND BLOCK LETTERS TO COMPLETE THIS FORM MAINSTREAM Programme Option: PUPIL DETAILS Middle Surname: name: name: Date of Flat or Male Female birth: house number: Area of Street: the city: Post Home contact Pupil code: phone no ( ) mobile no Parent/Guardian email Address Pupil email Address School name Year group EMERGENCY CONTACT DETAILS Parent/ Relationship Guardian name to pupil: Work Tel no Address Home Tel no If not available at above, please contact Relationship Name: to pupil Address Home Tel: Work Tel: Family Doctor name: Surgery address: Tel: Does your child suffer from any condition requiring medical treatment, including medication? YES NO If YES, please specify YES NO Is your son/daughter allergic to any medication? If YES please specify. Has your son/daughter received a tetanus injection in the last five years? YES NO Please outline any special dietary requirements of your child. I undertake to inform the GVP as soon as possible of any changes in the medical circumstances between the date on which this form is signed and the start of the programme which takes place regularly throughout the year. EQUAL OPPORTUNITIES Information Please tick only one of the options below which describes your child or tick this box if you do not wish to disclose this information: White Scottish White Irish Other British Mixed Indian Pakistani Bangladeshi Chinese Other Asian African Other Black Other ethnic background, please state (i.e. French etc) ________________________________________________________________ Please tick, if either of the options below apply to your child: Asylum Seeker Refugee Declaration of Parental Consent
Senior Programme College Participation Form PLEASE USE BLACK INK AND BLOCK LETTERS TO COMPLETE THIS FORM MAINSTREAM Programme Option: PUPIL DETAILS name: Middle name: Surname: Date of birth: Male Female Flat or house number: Street: Area of the city: Post code: Home contact phone no ( ) Pupil mobile no Parent/Guardian email Address Pupil email Address School name Year group EMERGENCY CONTACT DETAILS Parent/ Guardian name Relationship to pupil: Address Home Tel no Work Tel no If not available at above, please contact Name: Relationship to pupil Address Home Tel: Work Tel: Family Doctor name: Surgery address: Tel: Does your child suffer from any condition requiring medical treatment, including medication? If YES, please specify YES NO Is your son/daughter allergic to any medication? If YES please specify. YES NO Has your son/daughter received a tetanus injection in the last five years? YES NO Please outline any special dietary requirements of your child. I undertake to inform the GVP as soon as possible of any changes in the medical circumstances between the date on which this form is signed and the start of the programme which takes place regularly throughout the year. EQUAL OPPORTUNITIES Information Please tick only one of the options below which describes your child or tick this box if you do not wish to disclose this information: White Scottish White Irish Other British Mixed Indian Pakistani Bangladeshi Chinese Other Asian African Other Black Other ethnic background, please state (i.e. French etc) ________________________________________________________________ Please tick, if either of the options below apply to your child: Asylum Seeker Refugee Declaration of Parental Consent
College_Participation_Form.docx