IMPACT 4 Registration:

We would like your child to enjoy their IMPACT – 4 activity experience. We ask you take to time to complete the following questionnaire. The answers will allow us to prepare to meet your needs of your child and for us to gain the relevant permissions.

    Your Name

    Your Address

    Your Post Code

    Your Email

    Your Telephone

    Your Child's Name

    Your Child's Date of Birth

    Your Emergency Contact Details (name and number)

    School Name (required)

    Are you eligible for benefit-related free school meals?

    Do you have any allergies/dietary requirements?

    Please indicate YES or NO to the following questions:

    Does your child have a heart or respiratory condition?

    Does your child ever feel faint/suffer with dizzines/ever have a loss of consciousness?

    Does your child take medication, which the staffs need to be aware of?

    Does your child have a medical condition we need to be made aware of?

    Does your child have a hearing or visual impairment that may affect their participation?

    Does your child have any special education needs, which may affect their participation?

    Can your Child swim unaided?

    I declare with the best of my knowledge the information above is correct and that my child can participate in the IMPACT -4 activities and events. I will advise the Staff and management if there is a change in circumstances

    I hereby give my consent for child to take part of the IMPACT - 4 activities. My child is in good health and capable of taking part in the sessions. I give my consent for first aid to be administered to my child and I have given all relevant medical information on this form. I give consent for my child to be photographed / videoed as part of the IMPACT – 4 monitoring and evaluation process. I understand that whilst the staff will do their utmost to ensure accidents are prevented, they cannot necessarily be held responsible for any loss, damage, or injury suffered.
    Please select a response to accept/deny these terms and conditions.

    By completing this form I agree to the terms and conditions of use at the Ribble Valley Health & Wellbeing partnership and understand that the centre may contact me via email, SMS, telephone or post for the purpose of delivering the services to me. The information collected on this form (including but not limited to my personal data) will be used by RVHWP and third parties approved by RVHWP to enable the delivery of services.

    Please tick the box if you would like to receive information on RVHWP events, activities and promotions.

    By ticking this box I agree that RVHWP and third parties approved by RVHWP and acting on its behalf may contact me via email, SMS or post, using the personal data I have provided on this form, with information on events, activities and promotions.

    If you wish to unsubscribe from future email communication regarding RVHWP events, activities and promotions please send an email to and add unsubscribe to the subject line.

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