Thank you

Your Name*

First Last

Your Email*

Enter Email Confirm Email

Child's Details

Amount of children booking*

Child's 1 Name*

Child's 1 Date of Birth*

Child's 1 Current Age*

Child's 2 Name*

Child's 2 Date of Birth*

Child's 2 Current Age*

Child's 3 Name*

Child's 3 Date of Birth*

Child's 3 Current Age*

Parent / Guardian Details

Parent / Guardian Name*

Address

Address Line 1 Address Line 2 City Postcode

Emergency Contacts

Emergency Contact 1*

Relationship of Emergency Contact 1 to Child*

Child Health Questions

Does your child have or has he or she ever experienced the following?

High or low blood pressure?

Yes
No

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes
No

Chest pains brought on by physical exertion?

Yes
No

Childhood epilepsy?

Yes
No

Dizziness or fainting?

Yes
No

A bone, joint or muscular problems with arthritis?

Yes
No

Asthma or other respiratory problems?

Yes
No

Any sustained injuries or illness?

Yes
No

Any allergies?

Yes
No

Is your child taking any medication?

Yes
No

Has your doctor ever advised your child to exercise?

Yes
No

Is there any reason not mentioned above why any type of physical activity may not be suitable for your child?

Yes
No

If you have answered ‘Yes’ to any of the above questions, please write full details here:

Photography Disclaimer*

By clicking the checkbox you allow Rugby Nippers to use image(s), or those of your child(ren) if under 18, on Rugby Nippers website and other social media sites, including Facebook, Twitter, Instagram etc?

Yes
No

Would you like to be added to our News Letter?

We will write our amusing news letter with light lightheartedness, tips and news of our Rugby Nippers programme, on a monthly bases!

Yes
No

Parent / Guardian Signature

In signing this form, I the parent/guardian of the aforementioned child, affirm that I have read this form in its entirety and I have answered the questions accurately and to the best of my knowledge. I understand that my child is responsible for monitoring him or herself throughout any activity, and should any unusual symptoms occur, would cease participation and inform the instructor. I understand that if my child is below the age of six years, I the parent/guardian am responsible for monitoring him or her within their activities. In the event that medical clearance must be obtained prior to my child’s participation in a sports session, I agree to contact the GP and obtain written permission prior to the commencement of the sports activity, and that this permission be given to the instructor.

Parent / Guardian Signature:*

Date*

Name

First Last

Teaching Young Children The Very First Skills Of Rugby

Rugby Nippers Health Questionnaire

Child's Details

Parent / Guardian Details

Emergency Contacts

Child Health Questions

Parent / Guardian Signature

Follow Rugby Nippers Online:

Tel: 07748 133314

Email: info@rugbynippers.co.uk

About Us

Additional Resources

Mailing List