Ariel Othellos Wind in the Willows 2025 BUDDIES Application Form

First name

Last name

Date of Birth

Parent-Guardian First Name

Parent-Guardian Last Name

Phone

Address Line 1

Address Line 2

Address Line 3

Town

Post Code

Emergency Phone Number - Different to Phone Number Above

Emergency Contact Name

Relationship to student

2nd Emergency contact Number NOT the same as above.

2nd Emergency Contact Name

Do you give permission for the student to leave the workshop unattended

YES

Do you give permission for the student to leave the workshop at Lunch time unattended

YES

Medical conditions/allergies - please include instructions with regards to medication that may need to be administered. For allergies, please state what action should be taken in an emergency. Emergency Contact Details.

Has your child had any serious illness, operation or accident in the last year? If so, please give details.

Has your child had any illness during the past year? If so please give details.

Does your child have any difficulty with a) hearing or b) eyesight

Does your child require any medicines, or special treatment about which the Organisation should be informed? If yes, please give details with instructions/actions that need to be taken in the event of an incident.

Are there any other considerations Ariel should be made aware of? If yes, please give details with instructions/actions that need to be taken

Your Signature

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Wind in the Willows Buddies 2025