Please complete the form (one per child) for icc's 2013 Easter holiday club If you are human, leave this field blank. Child's FULL name * Date of birth * School year * Gender of child * Male Female Child's home language * Name of legal parent/guardian * Address * Email address * Mobile tel number * EMERGENCY Contact (Name) * EMERGENCY Contact (Mobile number) * Does your child have any allergies or medical conditions? * Yes No If YES, please give details MEDICAL CONSENT: I give permission for my child to receive emergency medical, dental or surgical treatment as considered necessary by the medical authorities present. * Yes No PERMISSIONS: I give permission for my child to attend and take part in the big top holiday club. * Yes No PHOTOGRAPHIC/VIDEO CONSENT: I give consent for my child to appear in photographs which may be used at events and/or for on publicity purposes including the icc website. * Yes No NAME OF PARENT: * I agree and give my permission for my child to participate in 'The Big Top' Holiday Club 2013 * I agree DATE: * Submit
