HOMESTART WEST SOMERSET HOMESTART WEST SOMERSET A COMPANY LIMITED

Home-Start

Home-Start

West Somerset

Home-Start West Somerset, a company limited by guarantee. Registered in England and Wales no. 5646970

Registered office: 26a The Avenue, Minehead TA24 5AZ. Registered charity no. 1113944

26a The Avenue, Minehead, Somerset TA24 5AZ

T 01643 707304

W www.homestart-westsomerset.org.uk

PARENTAL CONSENT AND INFORMATION FORM

Please delete as appropriate:

I agree to my children being cared for in my absence by my Home-Start volunteer.

I agree to my children taking part in outings accompanied by my Home-Start volunteer.

I give permission for my Home-Start volunteer to seek medical attention for my children in an emergency.

Please complete the following information (if there are more than 4 children please continue on reverse):

	Child 1	Child 2	Child 3	Child 4
Name
Date of birth
Name and phone number of doctor
Any allergies or medical info

PLEASE ENSURE YOU COMPLETE THE REVERSE OF THIS FORM

Date or regular day (if applicable)
Emergency contact number for parents
Whereabouts of parents
Estimated time of absence
Additional emergency contact names & numbers (at least one other than the parents must be listed)
Any specific instructions regarding the care of the child/children

Signed…………………………………. Printed…………………………………

Date...............

Relationship to children…………………………………………………

When completed and signed please return to the Home-Start office.