Booking Form - Aktiva
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1
2Grove Park Primary School
Clubs Booking Form
Please complete in BLOCK CAPITALS
CONTACT INFORMATION
Child’s Name
School attended
Year
Class
Age
Male
Female
Date of Birth
(please tick)
(dd mm yyyy)
Address
Post Code
Tel. No. 1
Tel. No. 2
Email
Person collecting your
child*
*You must inform AKTIVA CAMPS of any change to this named person
Who has legal contact with the above named child(ren)?
Who has parental responsibility for the above named child(ren)?
Name of G.P .
G.P.’s Tel. No.
G.P.’s Address
MEDICAL EMERGENCY
PAYMENT
Debit or credit card payments can be processed through our
In the event of __________________________ (full name of child)
accounts department, by calling 020 3551 8909.
requiring medical or surgical treatment, including the administration
(Please note for credit card payments there is an additional 2% charge).
of local or general anaesthetics in any emergency during his /
her stay at AKTIVA CAMPS, I hereby give my consent to such
I will pay via childcare vouchers.
treatment as may be considered necessary by a registered medical
practitioner.
Provider:
During their stay at the camp, will your child have any:
Amount:
£
Medical requirements? (e.g. asthma)
YES
NO
I will pay the full amount via bank transfer.
Dietary requirements?
YES
NO
YES
NO
Special educational needs or disability?
£
Amount:
If YES to any of the questions to the left, please attach additional
information.
Account:
Aktiva Camps Ltd
X
Bank:
HSBC Plc
No cheques or
Signed
Account No:
11402250
(Parent/Guardian)
cash please
Sort Code:
40-05-09
CONSENT & SIGNATURE
Please give your consent for us to use plasters in the event that your child has a minor injury.
Please give your consent for us to use cleansing wipes were deemed necessary.
Please give your consent for us to supply your child with sun cream that they will apply to themselves in hot weather.
Please give your consent for us to support your child in changing their clothes in the event of them becoming wet or soiled due to an accident
or during water or messy play.
Please tick if your child qualifies for FSM
X
Date
(Parent/Guardian)
Signed
Please return completed booking form to:
By signing this booking form, you agree to the terms
Aktiva Camps Ltd, 1 Lyric Square, London, W6 0NB
and conditions on the
Tel: +44 ( 0 ) 20 3551 8909
Building confidence and broadening experience!
Email: bookings @
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