Child's Name:
(Required)

Required Start Date:
(Required)

Date of Birth:
(Required)

Name of Primary Parent or Guardian:
(Required)

Address:
(Required)

Home phone:
(Required)

Work / Mobile phone:
(Required)

Email Address
(Required)

When would you like the Out of school club placement to start:
(Required)

Please choose the days that you require for the Breakfast Club:
(Required)
MondayTuesdayWednesdayThursdayFriday
Please choose the days that you require for the After School Club:
(Required)
MondayTuesdayWednesdayThursdayFriday

Please Note: Whilst we will endeavour to accommodate your child for the days that you require this is not always possible. We will communicate with you regarding availability on days and on start dates as early as possible.