EPSOM AND ST HELIER NHS TRUST

WILLOWS PLAYSCHEME
May 2015
FEES
Epsom and St Helier NHS - 17.00
Royal Marsden 18.00
Non trust, inc ICR 21.50 payable in advance please
Cheques payable to GBS RE EPSOMSTHELIER NHST

Office use only

Amount paid...
Payment
method
Invoice raised Y/N

Home address....................................................................................................

Parent given
confirmation of days
booked via a
photocopy of the
second page or
emailed back Y/N

Home telephone number.

Signed.

Parent / Guardian ..

Epsom and St Helier NHS/Royal Marsden/Non NHS (please delete as appropriate)

Job title..
Department
ASSIGNMENT NUMBER .
Extension Number
Emergency contact name..
Emergency contact number
Childs name..
Date of birth
Please give details of allergies, illnesses, special needs etc.
...
...
Do you consent to your childs photograph to be used in playscheme prospectus/newsletters/STEPS
magazine YES/NO (delete as appropiate
PASS WORD
Any other information regarding your child.
...
...
In the event of a sudden illness or accident affecting my child I agree to emergency treatment, if
recommended by a doctor.
Parent / Guardian signature..Date...

CONTACT NUMBER FOR THE PLAYSCHEME 0208 296 4459

Please remember: All booked days will be charged for regardless of attendance.

Tuesday 26th May

Wednesday 27th May

Thursday 28th May

Friday 29th May

Terms and Conditions

Parents must identify themselves to the playscheme supervisor on the first day of the childs attendance and ensure they
sign their child in and out
Adults collecting children must present themselves to a member of the team before escorting the child from the playscheme.
Unless requested or optional as part of an activity, children should not bring any money or valuable items to the playscheme. The
Trust will not be responsible for lost or damaged belongings.

CHILDREN MUST NOT BRING IN ANY EQUIPMENT THAT HAS A CAMERA

Children must bring a nutritional packed lunch including a drink every day.
Behaviour by any child that is considered by the staff to be disruptive, unacceptable or inappropriate will be monitored and
discussed with the parent or guardian.
The playscheme supervisor reserves the right to expel any child or adult from the playscheme should incidents occur which are
deemed serious to warrant such action.
Respect for, and proper use of all property, equipment and the premises is essential and must be maintained by all persons at all
times.
The playscheme opening hours are 7.45am to 5.45pm and all children must be collected by closing time. Any late collection will
be charged for at the following rates: up to 10 minutes late 5, and 2 for each 5 minutes thereafter. This charge will be added to
your invoice at the end of the period if not paid on the day.
The children will go on excursions outside the hospital. The Trust is not responsible for any untoward incident, providing due care
and attention is given.
All booked days will be charged for regardless of attendance.
Payment will be deducted from salary following the holiday period for Trust parents and non trust parents must pay when
booking their child in. I agree to the terms and conditions stated above and will explain all appropriate statements to my child.

Signature

Date .

Full name printed..

The amount you will be paying in vouchers for this holiday period.
..
ESTH PARENTS / CARERS ONLY. PLEASE DELETE AS APPROPIATE WHETHER YOU ARE DIRECTLY
INVOLVED IN THE MAJOR INCIDENT PROCEDURE.
I AM/AM NOT DIRECTLY INVOLVED IN THE MAJOR INCIDENT PROCEDURE
SIGNED DATE
Office use only

Terms signed

Booked on form

Parent informed