Millfield Pentathlon Group: Ages 13-17

Tuesdays:3rd September to 3rd December 2024

(Excluding 22nd October & 29th October 2024 due to Half-Term)

Your Child's Details

First Namerequired

Surnamerequired

Age at time of courserequired

Please select how old your child will be on the first day of the course

Date of Birthrequired (dd/mm/yyyy)

Gender*

Male Female

Additional Information (if required)

Medical Information, Additional Educational Needs and Dietary Requirements

Disclosing this information assists us with staffing, grouping and ensuring the welfare of your child; it does not automatically exclude your child from a course. If any questions are answered yes, we will contact you in confidence for further details.

In the event of an emergency staff will make every reasonable effort to contact a parent or legal guardian before permitting treatment to proceed as advised by the medical authorities present.

Please inform us immediately if any of this information changes after you have submitted your application form. It is imperative that we have the most up to date information to ensure we can provide a safe environment for your child.

Does your child have any medical conditions?*

No Yes

If yes, please provide details belowrequired

Is your child currently taking any medication?*

No Yes

If yes, please state the name, dosage and medication to be administered belowrequired

Please note that all medication brought on campus must be given to the Course Leader/Coach/Houseparent upon arrival. For reasons of safety, there are strict regulations for the management of medicines. Please do not send medicines with your child unless prescribed by a doctor together with an English translation of each medicine's dosage and contraindications (warnings, precautions and possible side effects).

Does your child receive additional support at school for additional educational needs including behavioural issues/emotional issues?*

No Yes

If yes, please provide details belowrequired

Does your child have any significant allergies (e.g. allergic to peanuts or pollen)? *

No Yes

If yes, please give the details of any symptoms and the name and dosage of any medication required below required

Please note that all medication brought on campus must be given to the Course Leader/Coach/Houseparent upon arrival. For reasons of safety, there are strict regulations for the management of medicines. Please do not send medicines with your child unless prescribed by a doctor together with an English translation of each medicine's dosage and contraindications (warnings, precautions and possible side effects).

Does your child carry an adrenaline auto-injector (Epinephrine)?*

No Yes

If yes, please ensure they bring two with them. One must be given to the Course Leader/Coach.

Does your child have any special dietary requirements (e.g. lactose free, gluten free or vegan)?*

No Yes

If yes, please provide details belowrequired

Is there anything else that you think we need to be aware of?

Parent/Guardian Details

Titlerequired

First Namerequired

Surnamerequired

Relationship to Childrequired

Address Line 1required

Address Line 2

City/Town/Villagerequired

County

Post Coderequired

Country

Primary Telephone Numberrequired

Secondary Telephone Number

Emailrequired

Emergency Contact Information

Please provide us with two emergency contacts who must be contactable for the duration of the course.

Emergency Contact 1

Would you like to use the Parent/Guardian details listed above as Emergency Contact 1?

If yes, we will use the primary contact number listed as the emergency contact number.

Yes No

First Namerequired

Surnamerequired

Relationship to Childrequired

Emergency Contact Numberrequired

Emergency Contact 2

First Namerequired

Surnamerequired

Relationship to Childrequired

Emergency Contact Numberrequired

Terms & Conditions

All bookings are subject to the Sports & Activity Courses Terms and Conditions which can be viewed here

Terms & Conditions*

I understand and accept all Terms & Conditions

Course Payment

I agree to pay the total displayed below.

Total Amount Due

By submitting this application form you acknowledge that from time to time we may send you news and updates from Millfield that we think will be of interest to you by post or e-mail. You can easily remove yourself from this mailing list at any time by e-mailing ‘unsubscribe’ to media@millfieldenterprises.com or by clicking the ‘unsubscribe’ button at the end of the newsletters that you receive by e-mail.

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