Membership Form

Please fill in the form below.
Or download a printable version.

Children will not be able to attend without a completed membership form, you can either complete below or complete at a SPLAT session.

If you have already completed a membership form, you do not need to complete another

Child 1 Details

Name

First Name Last Name

Gender

What is the ethnicity of the child named above?

White

English, Welsh, Scottish, Northern Irish

Irish

Gypsy or Irish Traveller

Any other White background - Please state

Any other Mixed or Multiple ethnic background - Please state

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background - Please state

Black

African

Caribbean

Any other Black background - Please state

Arab

If other, please state ethnicity

Address

Address Line 1 Address Line 2 City Post Code

Date of Birth

DD slash MM slash YYYY

Age

Is your child eligible for free school meals?

Yes

Name of School

Permissions

First Aid Permission

I give permission for staff to perform first aid / take my child to hospital in the event of a serious accident.

Yes

Photo Permissions

I give permission for SPLAT Staffordshire to take photos and publish any images of my child (On social media, other marketing etc).

Yes

Permission To leave

Children aged 10 years old and over are allowed to leave the session on their own, with your permission. If my child is aged 10 years old or over, I give permission for them to leave on their own (Please note, they will not be able to take any younger siblings home with them).

Yes

Medical Information

Is the child named above allergic to plasters?

Yes

Please list any allergies

Disabilities / learning support needs

Any medical conditions

Child 2 Details

Name

First Name Last Name

Gender

What is the ethnicity of the child named above?

White

English, Welsh, Scottish, Northern Irish

Irish

Gypsy or Irish Traveller

Any other White background - Please state

Any other Mixed or Multiple ethnic background - Please state

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background - Please state

Black

African

Caribbean

Any other Black background - Please state

Arab

If other, please state ethnicity

Address

Address Line 1 Address Line 2 City Post Code

Date of Birth

DD slash MM slash YYYY

Age

Is your child eligible for free school meals?

Yes

Name of School

Permissions

First Aid Permission

I give permission for staff to perform first aid / take my child to hospital in the event of a serious accident.

Yes

Photo Permissions

I give permission for SPLAT Staffordshire to take photos and publish any images of my child (On social media, other marketing etc).

Yes

Permission To leave

Yes

Medical Information

Is the child above allergic to plasters?

Yes

Please list any allergies

Disabilities / learning support needs

Any medical conditions

Child 3 Details

Name

First Name Last Name

Gender

What is the ethnicity of the child named above?

White

English, Welsh, Scottish, Northern Irish

Irish

Gypsy or Irish Traveller

Any other White background - Please state

Any other Mixed or Multiple ethnic background - Please state

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background - Please state

Black

African

Caribbean

Any other Black background - Please state

Arab

If other, please state ethnicity

Address

Address Line 1 Address Line 2 City Post Code

Date of Birth

DD slash MM slash YYYY

Age

Is your child eligible for free school meals?

Yes

Name of School

Permissions

First Aid Permission

I give permission for staff to perform first aid / take my child to hospital in the event of a serious accident.

Yes

Photo Permissions

I give permission for SPLAT Staffordshire to take photos and publish any images of my child (On social media, other marketing etc).

Yes

Permission To leave

Yes

Medical Information

Is the child above allergic to plasters?

Yes

Please list any allergies

Disabilities / learning support needs

Any medical conditions

Declaration

•The information I have supplied is to my true knowledge, i.e. age of children.;
•I understand if there are any safeguarding concerns regarding my child, SPLAT Staffs have the right to report these to the appropriate organisations and share my details.;
•I understand that SPLAT Staffs have the right to refuse entry, if misinformation has been given i.e. ages of children.;
•I understand emergency contacts must be available to contact, during the duration of the session, the child is attending.;
I have read SPLAT Staffs GDPR policy and am aware of why they collect data and how it maybe used.

Please Confirm

I agree with all statements above (Please tick)

Emergency Contact 1

Name(Required)

First Name Last Name

Phone(Required)

Relationship to Child

Emergency Contact 2

Name

First Name Last Name

Phone

Relationship to Child

Keeping you updated

SPLAT Staffs would like to keep you updated from time to time. How would you like to receive the latest updates and news? (please tick)

Phone

Post

None

Once completed, you will receive a confirmation email within 48 hours.

If your child attends a SPLAT Session within 24 hours of completing an online membership form, you will need to complete another membership form at the session you attend.

This is because, we need up to 48 hours to check through your completed online form, to ensure all contact details are correct.

Any personal information that is gathered, is in line with our GDPR policy and is safely secured.

You can view our GDPR policy here.

Membership Form

Please fill in the form below.Or download a printable version.

Child 1 Details

Permissions

Medical Information

Child 2 Details

Permissions

Medical Information

Child 3 Details

Permissions

Medical Information

Declaration

Emergency Contact 1

Emergency Contact 2

Keeping you updated

Please fill in the form below.
Or download a printable version.