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?

Please select...YESNO

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?

Please select...YESNO

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

Please select...YESNO

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

Please select...YESNO

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

Please select...YESNO

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

Please select...YESNO

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

Please select...YESNO

Can your Child swim unaided?

Please select...YESNO

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

Please select...YESNO

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.

Please select your response...I DO accept these terms and conditionsI DO NOT accept 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 sport@roefield.co.uk and add unsubscribe to the subject line.