Breakout Registration

Thank you for taking the time to register for Breakout. Please enter your details below.

Child's Details
Child's first name:
Child's last name:
Date of Birth (dd/mm/yyyy):
Address:
Postcode:
School attended
School class
Known allergies or conditions:
Parent's name:
Parent's telephone number:
Parent's email address:
Emergency contact name:
Emergency telephone number:
In the case of a major accident your child will be taken by ambulance, if possible, to the nearest casualty department and parents will be informed as soon as possible. Please tick the box to indicate your agreement with this procedure. If you do not wish this procedure to be followed, please detail your request below and bring this to the attention of a member of staff who will be happy to discuss this with you.
I consent to this procedure being followed for my child
Alternative procedure:
Did you know we have a Breakout Membership?
Breakout membership lasts for a whole school year - starting in September and finishing in July. During this period, your child will only have to pay £1.50 entrance fee each week instead of the normal £2.00 (obviously the nearer you join to September, the more you benefit). Breakout membership costs £5 per child, per year. Please tick the box if you wish to become a member (please bring the £5 membership fee to your child's first session).
I would like my child to be a Breakout member.
Please type the displayed letters then click the button to send your entry.
Important Note: After you click the Send Application button you will see a confirmation page. If you do not see this page we will have not receieved your application, so please try again.