This form must be submitted prior to attending any Holiday Camp. By submitting this form you are acknowledging that you have read, understood and agreed to our Privacy Policy here.

Name of Child *

First Name

Last Name

Date of Birth *

Family Doctor''s Name *

First Name

Last Name

Family Doctor's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Doctor's Phone Number *

Is your family covered by Private Medical Insurance?

Yes

Has your child ever suffered from any infectious diseases?

Please let us know about any serious illness, injuries, operations etc...

Does your child suffer from any allergies? *

Yes

Allergies

Does your child carry an epipen? *

Yes

Other medical conditions:

Dyslexia

Dyspraxia

Aspergers

Autism

Diabetes

Asthma

ADHD

Epilepsy

Are your child's vaccinations up to date? *

Yes

Do you consent to the reasonable use of antiseptic / plasters? *

Yes

In the event of an emergency we will make every effort to contact you. However we require your permission for emergency procedures to be carried out by qualified medical staff if necessary. I give permission for Starmaker Performing Arts staff to administer first aid to my child. *

I Agree

Please type your name in the box below to confirm your acceptance of our Terms and Conditions: *

Please type your name below:

I consent to being contacted by Starmaker Performing Arts regarding my child's submitted medical form. (Please tick the box below to confirm your opt-in) For more information on how we use your personal data, please click the Privacy Policy link. *

I have read and understood the Privacy Policy and I consent to being contacted by Starmaker Performing Arts.

Thank you for submitting your Holiday Workshop Medical Form.