Mind a Client - Community Cancer Care Givers Registration Page

Denotes required field

Firstname

Surname

Address Line 1

Address Line 2

Address Line 3

Address Line 4

County

Postcode

Mobile

Your relationship to the child

2nd Parent/Guardian Details

2nd Guardian relationship to child/ren

Emergency Name and full address and phone number

Childs Name

Childs Date Of Birth

Family GP/Practice Name and full address and phone number

Name of the Welfare Officer Assigned to the Patient

I/we understand that every effort is made to contact the main parent/guardian or emergency contact

I/We authorize the Childminder/volunteer trained in First Aid may administer First Aid to my child

I consent to temperature control medication in accordance with the policy &procedures of the Charity

Are your child/ren up to date on all Irish National Immunisation Schedule? if not provide details

Does your child/ren have any known allergies, medical conditions, take medication? if yes list here

Does your child/ren have any additional needs and/or physical or intellectual disability

Is there any additional requirements you would like to bring to our attention about your child

Permission to Process Data

Do you confirm that you have read the Data Privacy Notice available at Privacy Policy

I consent to the Charity contacting my named welfare officer in relation to my diagnosis: Letter

I confirm that these details are correct

EXIT