Emergency Contact

Additional Emergency Contact Name

Name Surname

Address*

Street Address Address Line 2 City Post Code

Emergency Telephone Number

Medical Details

GP Name

GP Address*

Street Address Address Line 2 City Post Code

GP Telephone Number

Section Break

Do you have a disability that you would like to share with us?*

Yes
No

If yes, please provide details of the disability including any help that you may need.

Do you have any dietary requirements or allergies we need to know about?*

Yes
No

If yes, please provide details.

Is there any additional information we need to be made aware of, including any fears or questions you may have prior to the group session?

Addition Info

Photograph & Video Declaration.*

I agree to the names above being kept on database for tracking and contact purposes.

Yes, I agree
No, I do not agree

Photograph & Video Declaration.*

At Once Upon a Smile, we love to share the amazing work we do at OUAS. This can include photographs and video with the possibility of sharing on our social media platforms.

Yes, I agree
No, I do not agree

I agree to the names above being kept on database for tracking and contact purposes.*

Yes
No

Permission to be contacted for feedback*

Yes
No

Permission to be contacted outside of the group session should you need to leave without informing OUAS staff, we do kindly ask you to speak to a member of staff prior to leaving.*

Yes
No

Date of Completion

Make a Donation

Parents Needs

Parent Needs Form

Emergency Contact

Medical Details

Section Break

Addition Info