Wicklow Hockey Club

* Your name (payer)

Your email (for receipt)

* Your mobile number

* Address

* Child 1: First Name

* Child 1: Last Name

* Child 1: DOB

* Child 1: GenderMaleFemale

* Child 1: Please outline any medical information (i.e. allergies, conditions, medication) which may impact on your child's health, welfare or behavior while participating in the camp

* Child 1: Are you a member of Wicklow Hockey ClubYesNo

* Child 1: Age

* Child 2: First Name

* Child 2: Last Name

* Child 2: DOB

* Child 2: GenderMaleFemale

* Child 2: Please outline any medical information (i.e. allergies, conditions, medication) which may impact on your child's health, welfare or behavior while participating in the camp

* Child 2: Are you a member of Wicklow Hockey ClubYesNo

* Child 2: Age

* Child 3: First Name

* Child 3: Last Name

* Child 3: DOB

* Child 3: GenderMaleFemale

* Child 3: Please outline any medical information (i.e. allergies, conditions, medication) which may impact on your child's health, welfare or behavior while participating in the camp

* Child 3: Are you a member of Wicklow Hockey ClubYesNo

* Child 3: Age

* Emergency Contact Name (if you cannot be contacted)

* Emergency Contact Number (if you cannot be contacted)

* I am aware that my Children's photograph or video image may be taken whilst attending or participating in games or activities connected with the Club and I consent to it being used by the Club for items like match programmes, year books, match reports, event reports or on the Club website or social media channels.

Founded 1996

Wicklow Hockey Club

Wicklow

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