Sportwise Child Health & Booking Form

Childs Name

Date of Birth

Name of School

Parents Name

Telephone Number

Mobile Number

Email Address

Address

Course

No online payment necessary. we will contact you if paying on card.

payment

Credit Card Cheque Bank Transfer Cash

* Payment can be made at the shop on Birmingham road.

Does the child have or has had a history of experience of any of the following:

Joint Problems

Yes No

Allergies or Reactions? (food, medicines, other)

Yes No

If yes please specify below...

Has the child had any recent illness/injury/surgery?

Yes No

If yes please specify below...

Any other information we need to be aware of?

I, the parent / guardian of the afore mentioned child, acknowledge the above information to be true and accurate. To the best of my knowledge, I have given all relevant information regarding the child's health and ability to participate safely in a physical activity programme.