Nichola Eddery Atelier – Parent/Guardian Consent Form

 

 

Name of Child ………………………………… Date of Birth ………………………...……………….………....

 

Parent/ Guardian ………………………………………………………………………………………....................

Address: ……………………………………………………………………………………...……………………..
………………………………………………………...……........................… Postcode ……………………….....
.

Tel (day): ……………………………..................  Tel (evening): ……………………….................………….......
Mobile: …………………………………………………….. e-mail: ……………………………...........................
 

Does your child require any special requirements, if so please state…                                                          ...................................................................................................................................................................................
………...…………………….………………………………………………………………………………..……..
…...……………………………………………………………………..……………………………..………….....
 

Emergency contact details:(If different from above)
Name: ……………………………………………………………… Telephone no:  ……………..…………….....
Relationship to child: ……………………………………………………………………………….........................
 

CONSENT (please read carefully)
 

1. I agree to my son/ daughter taking part in the activities of the program.

2. I confirm to the best of my knowledge that my son/ daughter does not need any special requirements other than those listed above.

3. I confirm I have booked the lesson/s and agreed to the terms and conditions stated on the website www.nicholaedderyatelier.com.

 

 

 

Signed ………………………………….....................… (Parent/ Guardian) Date: ……………………………