impact Academies & Camps
Enrolment Form
Child details
Name and surname
Date of birth
Adress & postcode
Parent/Guardian details 1
Name and Surname
Work tel No:
Mobile No:
Company/Employer Address
Email
Does this parent have parental responsibility?
Yes
No
Does this parent have legal access to the child?
Yes
No
Does the child live with this parent?
Yes
No
Parent/Guardian details 2
Name and Surname
Work tel No
Mobile No
Company/Employer Address
Email
Does this parent have parental responsibility?
Yes
No
Does this parent have legal access to the child?
Yes
No
Does the child live with this parent?
Yes
No
Emergency contacts
You must provide at least one emergency contact!
Contact 1
Name and Surname
Relationship
Tel No
Contact 2
Name and Surname
Relationship
Tel No
Contact 3
Name and Surname
Relationship
Tel No
Medical information
Doctors Name
Doctors Address
Doctors Telephone
Details of any medical problems or special needs:
Details of any allergies or other medical conditions we should be aware of:
If the child needs to take any medication during his time at impact A&C, a parent consent is needed.
Download the Consent letter, fill it in and return a signed copy to leicester@impactacademies.co.uk
PARENT/GUARDIAN CONSENT AND AGREEMENT FOR EMERGENCIES
As parent/guardian, I consent to have my child receive first aid by facility staff and, if necessary, be transported to receive emergency care. I give consent for the emergency contact person listed above to act on my behalf until I am available. I agree to review and update this information whenever a change occurs and at least every 6 months.
Terms & Conditions
I have read and agree to the Terms & Conditions.
Your child will be attending a two hour lesson per week on weekdays between 18:00-20:00 or a 2 hour lesson on weekend between 09:00-19:00
Please create a word password for picking your child at the end of the lessons
It can be 1 simple word (up to 12 characters)
You consent that your child is old enough to come and leave our premisses without supervision
YES/NO
Submit