Springer’s Registration Form

Information submitted with this registration form will be treated with the strictest confindence and will comply with GDPR

Child's legal name

Child's preferred name

Address

Date of Birth

Please select the sessions you require

Monday

Full day (8:30am - 5:30pm) Morning (8:30am - 1pm) Afternoon (1pm - 5:30pm) After School Club (1:30 - 5:30pm)

Tuesday

Full day (8:30am - 5:30pm) Morning (8:30am - 1pm) Afternoon (1pm - 5:30pm) After School Club (1:30 - 5:30pm)

Wednesday

Full day (8:30am - 5:30pm) Morning (8:30am - 1pm) Afternoon (1pm - 5:30pm) After School Club (1:30 - 5:30pm)

Thursday

Full day (8:30am - 5:30pm) Morning (8:30am - 1pm) Afternoon (1pm - 5:30pm) After School Club (1:30 - 5:30pm)

Friday

Full day (8:30am - 5:30pm) Morning (8:30am - 1pm) Afternoon (1pm - 5:30pm) After School Club (1:30 - 5:30pm)

Persons with the Parental Responsibility i.e Mother, Father or Guardian

First Person

Name

Address

Mobile Number

Work Telephone

Home Telephone

Email Address

Doctor's Name

Doctor's Address

Doctor's Telephone

Doctor's Email

Second Person

Name

Address

Mobile Number

Work Telephone

Home Telephone

Social Worker Name (if applicable)

Social Worker Address

Social Worker Telephone

Social Worker Email

Details of those authorised to collect your child/children from us

First Person

Relationship to child

Telephone Number

Second Person

Relationship to child

Telephone Number

Third Person

Relationship to child

Telephone Number

Emergency Contact information

Note: If the name of the contact person changes, please inform the manager.

Doctor's Name

Doctor's Telephone

Doctor's Address

Name

Telephone

Address

Immunisation

Please check the box if the child has been immunised for the following

Does your child attend hospital for any reason?

Is your child on regular medication of any kind?

Is your child on a special diet?

Does your child suffer from any allergies?

Does your child have any problems with sight/hearing/speech?

In the event of a medical emergency do you consent to your child being transported to hospital by a member of our staff?

Any other relevant medical information?

Everyone Made Welcome

Established in 1997, Forthspring Inter Community Group is an inclusive and innovative organisation based in a shared space at the Springfield/Woodvale interface in Belfast. We seek to enhance life opportunities and to enable sustained relationships through a varied range of programmes and activities.

Phone: +44 28 9031 3945
Email: info@forthspring.com

Address:
373 Springfield Road,
Belfast, BT12 7DG