Svivaformnp - Bnei Akiva UK

Sviva Signup Form - NP

"*" indicates required fields

Child's Name*

First Last

Date of Birth*

This field is hidden when viewing the form

Sviva (old)*

This is the location of your Bnei Akiva group e.g. Golders Green

Sviva*

This is the location of your Bnei Akiva group e.g. Golders Green

Shevet (Year Group)*

Emergency Contact Name*

First Last

Emergency Contact Mobile Number*

Emergency Contact Home Telephone Number*

Email address*

Emergency Contact Address*

Street Address Address Line 2 City Post Code Country

Does your child suffer from any allergies that we should be aware of? e.g. Plasters, penicillin, food? Please give full details below. Withholding information may endanger the health or well-being of your child.*

Please give full details of any physical health conditions that may affect your child at sviva. e.g. Asthma, diabetes, epilepsy. Withholding information may endanger the health or well-being of your child.*

Please give full details of any mental health condition that may affect your child at sviva. e.g. ADHD, eating disorders, anxiety. Withholding information may endanger the health or well-being of your child.*

Approximate date of last Tetanus injection*

Do you feel that your child will need any extra support at sviva? If so, please contact welfare@bauk.org

Terms and conditions (to be signed by parent/guardian if under 18)*

I hereby declare that to the best of my knowledge, tthis medical form is accurate and complete in all its details. I understand that Bnei Akiva will not be responsible for any medical condition either physical or emotional, which may result from my failure to disclose relevant information. It is permissible for the designated First Aider to administer Savlon and plasterse, etc., for any minor ailments. I have read and agree to the above conditions.

I am happy to be added to any local Facebook or WhatsApp groups where information about my local Sviva will be shared by the Rosh and Madrichim.

Yes

I give permission for Bnei Akiva and Bachad to contact me and those listed in this form in regards to Bnei Akiva/Bachad events.

Agree

Sviva Signup Form - NP

London

Manchester

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