Childs Name: *


Childs Age: *
9 10 11 12 13 14 15 16 17 18

Childs Date of Birth: *


Gender: *
Male
Female

Home Address: *


Course Your registering for: *
27th /28th /29th JULY 2010 - £25 for 1 day, £45 for 2 days or £65 for 3 days 26th/ 27th AUGUST 2010 - £25 per day or £45 for 2 days

Parent / Guardians Name: *


Contact email address: *


School Attended:


Emergency Contact: *


Alternative Contact Details: *


Special Medical Information:


Food Allergy (please specify / none):


Insect Bite Allergy etc (please specify):


Allergic to Plasters (Yes /No) :
Yes
No

Can we apply plasters if needed (Yes / No): *
Yes
No

Any other specific medical information:


Although it highly unlikely that your child will become injured during the camp, 
please sign below to give your consent that in an emergency your child can 
be taken to the nearest A & E department.
We will always try to contact you on your contact details before this course of 
action is taken.
I agree that the staff at the Rugby Camp may take my child to A&E if deemed necessary (Please note that Rugby, Under 9's & Upwards is a contact sport): *