Chip Cafe Registration Form


Welcome to Chips

Please Register by filling in the questions below.

A seperate form is required for each person registering.

Name of the person enrolling for Chips:*
Parent/ Guardian's Name:*
Home Telephone number:
Mobile Number:
Email Address for updates:
Emergency contact during club (Name & Number):*
School /College /Uni:
Name and Number of the young person's G.P.:*
Any illnesses or other medical conditions (e.g.Asthma) allergies/ medication which may affect normal activity?:
In the event of illness or accident, if neither Parent or emergency contact can be contacted I give permission for the young person to receive any necessary medical trreatment from a qualified First Aider or medical practioner.:*
I Agree
No I dont Agree
I give permission for photographs to be taken, which may be used in Church or newspaper publications including the church website.:*
I Agree
No I dont Agree
If there are any other details that you think we should know please enter them here or if you can help during the week also please enter here.:
by checking this box you are electronically signing this form as a true statement and enrolling the person named above for the 2017 Chips Cafe:
I agree Please Enroll the person named for Chips Cafe
Please enter the verification number on the right:*
Five Free Too Five Six
* Required Fields

Chips Cafe
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