1. STARTER PACK
Contents:
Membership Application Form
Booking Information Form
Allergy Information Form
Local Activity Consent Form
Medical Information/Consent Form
Photography Consent Form
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012

2. c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch PA12 4DG
MEMBERSHIP APPLICATION
Name of Family _______________________________________________
Name of child(ren) (1) _________________________________ DoB _____________________________
(2) _________________________________ DoB _____________________________
(3) _________________________________ DoB _____________________________
I WOULD LIKE TO ENROL THE ABOVE NAMED CHILD(REN) WITH LOCHWINNOCH OUT OF SCHOOL CLUB
I understand that my membership is valid from ______________________ until one month’s written notice of cancellation is
received by the Club. I enclose a one off registration fee of £10 (Cheques payable to LOSC)
Parent signature
Please print name
Address
Telephone number
E-mail Address
Date
Payment Agreement
• I understand that I will be invoiced monthly for all the childcare that I have booked if my child attends the Club or not.
• I understand that one month’s notice must be given when cancelling of my child’s space or altering booked sessions.
• I understand that bills must be paid by the date stated on the invoice or may be subject to a late payment fee
I agree to comply with the above
Signed___________________________________________ Date ________________________
-------------------------------------------------------------------------------------------------------------------------------------------
This section will be completed by LOSC and returned to you
Certificate of Membership
This is to certify that the undernoted child(ren) has been enrolled in Lochwinnoch out of School Club
Manager’s Signature:
Telephone Number: 07757 801042
Date:
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012

3. c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch PA12 4DG
BOOKING INFORMATION FORM
Name of Child(ren)
School
Class/es
Name/Address and Telephone Number of Parent/Guardian
Name
Address
Telephone
E-mail
Does your child have additional support needs Yes / No
If yes please specify requirements
PLEASE TICK DAYS AND TIMES REQUIRED
Day Breakfast 3-5pm 3-6pm 4-5pm (S1/2) 4-6pm (S1/2)
Monday
Tuesday
Wednesday
Thursday
Friday
The forms in this pack, together with your membership fee should be returned to:
Lochwinnoch Out of School Club
c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch
PA12 4DG
Tel: 07757 801042
We will advise you as soon as possible if we are able to offer your child a place at the Club
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012

4. c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch PA12 4DG
ALLERGY INFORMATION FORM
NAME ______________________________________________ DoB _______________________
ADDRESS
_______________________________________________________________________________
_______________________________________________________________________________
ALLERGY _______________________________________________________________________
SYMPTOMS (Please describe in detail all the signs and symptoms your child may experience)
TREATMENT AUTHORISED (Parents must complete medication form if applicable)
GP DETAILS
Name __________________________________________________ Phone Number ______________________
Address _____________________________________________________________________________________
Signature of Parent ________________________________ (consent to medication when required)
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012

5. c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch PA12 4DG
LOCAL ACTIVITIES CONSENT FORM
As part of the LOSC responsibility for the health and safety of participants in approved activities, it is important that
the Play Leader be aware of any medical conditions your child has. Completion of this form is therefore a
requirement for all children participating in specified LOSC activities.
Name of Child _______________________________________________________ DoB _________________
Address_________________________________________________________________________
Home Tel No _____________________________ Mobile Tel No ___________________________
1) Emergency Contact Name ____________________________________
Relationship to child: __________________________ Phone: _________________________
2) Emergency Contact Name ____________________________________
Relationship to child: __________________________ Phone: _________________________
3) Emergency Contact Name ____________________________________
Relationship to child: __________________________ Phone: _________________________
Name & Address of GP: _____________________________________________________________
Tel No: ____________________________________
Authorised Collection from Club:
Name ________________________________ Name ___________________________________
Relationship to Child ____________________ Relationship to Child _______________________
I agree to my child participating in activities in and around Lochwinnoch such as visits to playgrounds, Library,
RSPB, Castle Semple Centre and supervised outdoor activities eg. football, rounders.
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012

6. c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch PA12 4DG
MEDICAL INFORMATION/CONSENT
1) Does your son/daughter suffer from any medical condition that could require expert medical attention?
YES/NO (If the answer is YES please provide further details)
____________________________________________________________________________________
____________________________________________________________________________________
2) Does your son/daughter have any allergies or reactions to drugs (this includes natural therapies)? YES/
NO
(If the answer is YES please provide further details including reactions, treatment requirements etc. You
may be asked to discuss this condition in detail with the Play Leader/Manager)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3) Does your son/daughter have any special dietary requirements? YES/NO (Details if applicable)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5) Does your son/daughter have any special needs (eg. wheelchair)? YES/NO
__________________________________________________________________________________________
6) Date of last tetanus toxoid booster (immunisation is voluntary)? ____________________
7) Are there any other matters or circumstances that will/could affect your son/daughter’s participation in an
activity?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012

7. c/o Lochwinnoch Primary School
Calder Street, Lochwinnoch PA12 4DG
I, _________________________________________________ being parent/guardian of the above named child
hereby give permission for the LOSC Staff to give the immediate necessary authority on my behalf for any medical
or surgical treatment recommended by competent medical authorities, where it would be contrary to my son/
daughter’s interest, in the doctor’s medical opinion, for any delay to be incurred by seeking my personal consent.
I declare that the answers to the above questions are true, that I have not withheld any relevant information
Signed ______________________________________ Date: ______________________________
PHOTOGRAPHY/VIDEO CONSENT
During the sessions, photographs and videos may be taken of your child for example on outings, outdoor play etc.
These photographs are displayed for parents and visitors and may also be used on Lochwinnoch Out of School
Club’s website (www.lochwinnochoutofschoolclub.co.uk)
I *give/do not give permission for my child to be photographed/videoed
Signed ______________________________________ Date: ______________________________
*Delete as appropriate
Information on this form will remain confidential to the Play Leader, and associated
administrative support personnel
Lochwinnoch Out of School Club is a Registered Scottish Charity – SC036990
Starter Pack Revised June 2012