Juventus Academy Football Programme – Spring Meadow Edutainment

Participant's Name

First Last

Age

Gender

Class

Parent's Information

Name	Phone Number	Email Address	Relationship

Child's Allergies

Any health issues

Yes
No

If yes, please specify

Is your child on any medication?

Do we have your permission, in the event of an emergency to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat your child as they may deem advisable.

Yes
No

Doctor's Contact

Parent’s consent

Meadow Hall has authorization, in the event of an emergency and in case I am not reachable, to authorize any medical personnel to attend or treat my child as deem advisable.

Authorization

I authorize Meadow Hall to use my child’s photograph/video recording (individually or in group) for educational or promotional purpose.

Agreement

By checking this box, you attest that the information contained in this form is correct and you agree to comply with the policies and fee statement.

Date

I hereby acknowledge that I have read and understood the terms and conditions as provided in this web page.

Agree

Payment

For electronic transfers, please find below the account information. Account name: Spring Meadow Limited Account number: 0013729058, Stanbic IBTC Bank Alternatively payments can be made at the Accounts Department

Please upload proof of payment here or send to gsamuel@meadowhallgroup.com