CHILD / YOUNG PERSON'S DETAILS
First Name:	* required	Surname:	* required
Date of Birth:			* required
Current Age:	4 5 6 7 8 9 10 11 12 13 14 15 16	Child’s Gender:	Female Male
PARENT / GUARDIAN DETAILS (please inform us if either parent does not have legal parental responsibility)
Title:	* required	Title:
First Name:	* required	First Name:
Surname:	* required	Surname:
Home Address:		Home Address:
Home Telephone Number:	* required	Home Telephone Number:
Mobile Number:		Mobile Number:
Email Address:	* required	Email Address:
ALTERNATIVE EMERGENCY CONTACT INFORMATION (please provide details of two people we can contact if we are unable to get hold of you)
Full Name:	* required	Full Name:	* required
Address:		Address:
Telephone Number:	* required	Telephone Number:	* required
Mobile Number:		Mobile Number:
Relationship to the child:	* required	Relationship to the child:	* required
FREE CLUB SESSIONS YOU WISH TO BOOK (Pick only one week number)
Week 1 - 04/02/12	Group 1 - ages 6 - 8 years old. 17:00 - 18:00 Beginners Chinese/Mandarin 13:00 - 14:00 Key Stage 2 English 12:00 - 13:00 Key Stage 2 Mathematics	Group 2 - ages 9 - 11 years old. 17:00 - 18:00 Beginners Chinese/Mandarin 14:00 - 15:00 Key Stage 2 English 13:00 - 14:00 Key Stage 2 Mathematics	Group 3 - ages 12 - 14 years old. 14:00 - 15:00 Key Stage 2 Mathematics
Week 2 - 11/02/12	17:00 - 18:00 Beginners Chinese/Mandarin 13:00 - 14:00 Key Stage 2 English 12:00 - 13:00 Key Stage 2 Mathematics	17:00 - 18:00 Beginners Chinese/Mandarin 14:00 - 15:00 Key Stage 2 English 13:00 - 14:00 Key Stage 2 Mathematics	14:00 - 15:00 Key Stage 2 Mathematics
Week 3 - 18/02/12	17:00 - 18:00 Beginners Chinese/Mandarin 13:00 - 14:00 Key Stage 2 English 12:00 - 13:00 Key Stage 2 Mathematics	17:00 - 18:00 Beginners Chinese/Mandarin 14:00 - 15:00 Key Stage 2 English 13:00 - 14:00 Key Stage 2 Mathematics	14:00 - 15:00 Key Stage 2 Mathematics
Week 4 - 25/02/12	17:00 - 18:00 Beginners Chinese/Mandarin 13:00 - 14:00 Key Stage 2 English 12:00 - 13:00 Key Stage 2 Mathematics	17:00 - 18:00 Beginners Chinese/Mandarin 14:00 - 15:00 Key Stage 2 English 13:00 - 14:00 Key Stage 2 Mathematics	14:00 - 15:00 Key Stage 2 Mathematics
Do you give us permission to allow your child to leave the club premises unaccompanied (in the case of older children):		Yes No
DECLARATION I agree to Brilliant & Brighter Futures Limited processing personal data contained in this form, or other data that Brilliant & Brighter Futures Limited may obtain from other people or me whilst my child is registered. I agree to the processing of such data for any purpose connected with my child or my child’s health and safety whilst on the premises or for any other legitimate reason. I declare that I have read, understand and agree to abide by the Club rules listed it the 'Parents Contract' section. The information I have given is true to the best of my knowledge. I agree to abide by the Club rules as published and to pay all fees by the due dates. I further declare that I have no outstanding debt to the Club.
		By pressing submit you agree with the above declaration and to all terms and conditions which may be modified at any time without notice. By pressing submit you will be registered with Brilliant & Brighter Futures Limited Supplementary Education Club.