Kingdom Champions – Coleraine Baptist Church

Join us all week long for our holiday bible club!

Please fill in the form for each child you wish to register separately.
This form needs to be filled out by a parent/guardian.

Child's Details

First name

Surname

Male or Female

Date of Birth

School Year/Class

Address & Postcode

Name of GP

GP Phone Number

Details of any medical conditions or allergies (e.g. Asthma/Diabetes/Epilepsy) and any medication

Any other special needs, requirements or directions that would be helpful for leaders to know about

Your Details

Your Name (Parent/Guardian)

Email Address

Phone number(s) where I can be contacted in an emergency:

Home Tel

Work Tel

Mobile Tel

If unavailable, contact:

Name

Phone Number

Relationship to Child

Acceptance of details use

I will inform the leaders of any changes to my child’s health; medication needs and also to any changes of address or phone numbers given. In the event of illness or accident, having parental responsibility for the above named child, I give permission for first aid to be administered where considered necessary by a trained first aider, if available, or by a suitably qualifi ed medical practitioner. If I cannot be contacted and my child should require emergency hospital treatment, I authorise an adult leader to sign on my behalf any written form of consent required by the hospital. However I understand that every effort will be made to contact me as soon as possible.

Photography consent

I give my permission for my child to appear in photographs/video filming that may be taken during the group.

Marketing Consent

I'm happy to receive additional emails from Coleraine Baptist Church about other relevant events and news.