Ham Manor Golf Club

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Parental Consent Form

Junior Name
Date of Birth
Address
Contact Number
Junior's Email Address
Parents Names
Address
Parents Address (if different)
Home Telephone Number
Mobile Telephone Number
Work Telephone Number
Parents Email Address
1st Emergency Contact - Relationship to Child
Home Telephone Number
Mobile Telephone Number
Work Telephone Number
Email Address
2nd Emergency Contact - Relationship to Child
Home Telephone Number
Mobile Telephone Number
Work Telephone Number
Email Address
Please confirm details of all those with Parental Responsibility for the Child
Child's Doctor's Name
Doctor's Surgery Address
Doctor's Telephone Number
Does your child experience and conditions requiring medical treatment and/or medication? Yes
No
If yes please give details, including medication, dose and frequency.
Does your child have any allergies? Yes
No
If yes please give details.
Does your child have any specific dietary requirements? Yes
No
If yes please give details.
What additional needs, if any, does your child have e.g. needs help to administer planned medication, assistance with lifting or access, regular snacks?
Do you consider your child to have a disability? Yes
No
Does your child have any communication needs e.g. non-English speaker/hearing impairment/ sign language user/dyslexia? If yes, please tell us what we need to enable him/her them to communicate with us fully.
I confirm to the best of my knowledge that my child does not suffer from any medical condition other than those detailed above.
I agree to notify the Club of any changes to this information. Yes
No
I give my consent that in an emergency situation, the Club may act in my place, if the need arises for the administration of emergency first aid/or other medical treatment which, in the opinion of a qualified medical practitioner, may be necessary. Yes
No
I acknowledge that the club is not responsible for providing adult supervision for my child, except for formal junior golfing coaching, matches or competition.
I can confirm that my child has my permission to be on the golf club's premises.
I agree to my child being transported by the club representatives to and from venue when he/she is representing the club. Yes
No
By adding my child's in the box below, I confirm that I have legal responsibility for them and I am entitled to give this consent and I am aware of how the information I have provided may be used.
Signed by Parent/Carer (please type full name)
Date
Confirm

West Drive, Angmering, West Sussex, BN16 4JE
Telephone No. - 01903 783288

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