Amber Valley School Sport Partnership CIO

Belper Leisure Centre – Holiday Camp

Address: John O’Gaunts Way, Belper DE56 0DA

8:30am – Drop off   3:00pm – Collection

Camp Dates: Mon-Thu  27th to 30th October

Cost: £20 per child, per day

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Number of Children*:
If you require a booking for more than 3 Children, please complete a second booking form.

Child 1 Full Name*:

Child 1 D.O.B* (dd/mm/yy) Children must be aged 5-11 years old:
Invalid date (dd/mm/yy).

Child 1 Emergency Contact Number*:

School*:

School Year*:

Medical Info*:

Dietary Requirement/Allergies*:

Special Educational Needs/Disability Information*:

Does your child recieve regular 1to1 support in school?*:
 Yes No


Please only complete Child 2 details if you have selected 2 Children from the option above.

Child 2 Full Name:

Child 2 D.O.B (dd/mm/yy) Children must be aged 5-11 years old:
Invalid date (dd/mm/yy).

Child 2 Emergency Contact Number:

School:

School Year:

Medical Info:

Dietary Requirements/Allergies:

Special Educational Needs/Disability Information:

Does your child recieve regular 1to1 support in school?:
 Yes No


Please only complete Child 3 details if you have selected 3 Children from the option above.

Child 3 Name:

Child 3 D.O.B (dd/mm/yy):

Child 3 Emergency Contact Number:

School:

School Year:

Medical Info:

Dietary Requirements:

Special Educational Needs/Disability Information:

Does your child receive regular 1to1 Support in school:
 Yes No



Parent Name*:

Email*:

Phone* (please ensure that you have provided us with two different contact numbers):

Postcode*:


Any Additional Info:


Do you agree to photos to be taken of your child for marketing and promotional materials?  Yes No

Do you agree to your child/children walking to and using the facilities at one of our Partner Sites? (see risk asssessment for more info)  Yes No

Do you agree to information being stored and processed for communication purposes in accordance with GDPR?  Yes No

Please tick to state you have read and agree to our Terms and Conditions.  Agree


If you child has a Belper Junior Active membership, please enter their membership number:

Belper Junior Active Member Discount Code: (this code has been provided to you by Belper leisure centre)

Your booking will be for the following dates:...

Total booking cost to be paid upon completing booking: £0.00

If you have any queries please direct them to holidaycamps@avssp.co.uk or call 01773 417204 – Option 2

You can find our Terms and Conditions and Risk Assessments for our holiday camp provision by clicking the links below.

Terms and Conditions

AVSSP Holiday Camp Risk Assessment