CG Box-Kids ParQ

Child's Name *

First

Last

Parent/ Guardian Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Child's Date of Birth *

Child's Age *

Emergency Contact *

First

Last

Emergency Contact Number *

GP Surgery Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GP Telephone Number *

Does your child have or has he or she ever experienced any of the following (please higlight): High or Low Blood Pressure *

Elevated blood cholesterol *

Diabetes *

Chest pains brought on by physical exertion *

Epilepsy *

Dizziness or fainting *

Any bone, joint or muscular problems with arthritis *

Asthma or respiratory Problems *

Any sustained injuries or illness *

Any allergies *

Is your child taking any medication *

Is there any reason not mentioned above why any type or physical activity may not be suitable for your child *

If you have answered ‘YES’ to any of the above questions, please give full details below and speak to a CG Box-Kids instructor *

I give permission for my child’s photo to be taken and used on social media to promote CG Boxkid classes *

Name

In signing this form, I the parent/guardian of the aforementioned child, affirm that I have read this form in its entirety and I have answered the questions accurately and to the best of my knowledge. understand that my child is responsible for monitoring him or herself throughout any activity, and should any unusual symptoms occur, my child understands the importance of informing the CG Box-Kid instructor immediately.

I understand that if my child fails to behave in a manner that is polite and respectable, he or she could be suspended from that particular session or future sessions.

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CG Box-Kids ParQ