Online School Year 6 and Year 11 Registration Page

Child or young person's details - Name:(required)

Home address:(required)

Post code: (required)

Telephone number:(required)

Email:(required)

Date of birth:(required)

Parent or carer's details - Name:(required)

Home address:(required)

Post code:(required)

Telephone number:(required)

Email:(required)

Emergency contact number - Name: (fill in if different from the person named above)

Home address:

Post Code:

Telephone number:

Email:

Child's medical details - GP:(required)

Address:(required)

Post Code:(required)

Telephone number:(required)

Email:

Any extra help we need to provide: (for example because of a disability)

Any medical conditions or allergies? (If yes, please provide details/medication needed)

Is there anything else you think we should know?

I agree to (please tick):(required) my child taking part in the online learning with Goshen Classroom.

keeping a record of this form for health and safety reasons

my child being filmed or photographed during the activity

with the possibility that these photographs/media recordings may be used for publications or marketing publicity.

Note: if consent is not given

Goshen Classroom will not use any images taken during the activity that contain the child/young person.

I understand that my child needs to follow the behaviour code and any safety rules so that Goshen Classroom can keep them and other children safe.

Print Name:(required)

Signature:(required)

Date:(required)

Child Consent: I understand that being safe means I need to follow the behaviour code and safety rules - Print Name:

Signature:

Date:

Please note that by clicking the submit button you have given your consent for your child to participate in the online tutoring. You have also agreed that, as part of this program, your child will be tutored during the day by an adult volunteer. You also give your permission for your child’s photo, video, sound recording, first name and creative works in, and for promotion of, Goshen Classroom Learning programs.

Thank you!

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Online School Year 6 and Year 11 Registration Page

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