For more information and the application form ... - Fusion Lifestyle

Ethnicity
White British Mixed White & Black Caribbean Asian Indian
White Irish Mixed White & Black African Asian Pakistani
White Other Mixed White & Asian Asian Bangladeshi
Other Mixed Other Asian Other
Chinese Black Caribbean Black African
Leaving the centre
Please state below whether you authorise your child to leave the camp by themselves at the
end of the session or whether you will sign them out. Please note that if you want to collect
your child, you must be at the facility by 12pm latest every day as staff and representatives
at the centre will cease responsibility of your child at 12pm each day at the latest.
Parent/Guardian consent statement
My child is in good health and I do not see any reason why they cannot take part.
I have completed the medical details and consent that in the event of any illness or accident, any
necessary treatment can be administered to my child, which may include the use of anaesthetic.
I understand that while the staff and representatives at the centre will take every precaution to ensure
that accidents do not happen, they cannot necessarily be held responsible for any loss, damage or injury
suffered by my child.
I understand that if my child acts in an inappropriate manner, such as foul language or abusive
behaviour, the staff and representatives have the right to immediately exclude my child from the camp
and prevent my child from attending future sessions. In this circumstance, my child will cease to become
the responsibility of the staff and representatives and I will be notified of this.
Please note that to help promote the centre and its participants, official photographs may be taken
during our sessions. These photographs may be used for official publications or in the media and will not
be passed on to any other parties.
If you do not wish for your child’s photograph to be published, please tick this box
If you do not wish for your child to be photographed at all, please tick this box
Parent/Guardian name (capitals)
Signature of Parent/Guardian
Date
Southwark leisure and sports centres are brought to you by Southwark Council, working in
partnership with Fusion. As an experienced sport and leisure organisation and a registered
charity, Fusion continually reinvests to improve and develop what’s on offer in your community.
Geraldine Mary Harmsworth Sports Facility
Free activities
Including… basketball, street dance and Tag Rugby
Weekly sports camps in August

For an action packed week full of exciting free activities, why not learn skills and
make new friends at Geraldine Mary Harmsworth Sports Facility during your
summer holidays? Pop in to book your place.
The weekly summer programmes will offer your child a range of activities in a fun
and safe environment. The sessions will take place each week day at 10am to
12pm (9am start on Mondays) in August.
Bookings
Bookings will be taken for the whole week and not individual days. Please fill
in the attached booking and consent form. This will need to be returned to
Geraldine Mary Harmsworth Sports Facility in person to confirm your child’s
place. You will receive an information document upon confirmation from
a member of staff. Geraldine Mary Harmsworth Sports Facility is open on
weekdays 9am to 8pm and 9am to 5pm on weekends. It is based in the Imperial
War Museum’s grounds and is situated off Geraldine Street.
Call us or pop in.
Geraldine Mary Harmsworth
Sports Facility
St. Georges Road
SE1 6ER
020 7735 3294
Free activities
Booking form
I would like to reserve a place on the following week
Monday 9 August to Friday 13 August (12 to 15 year olds)
Monday 16 June to Friday 20 August (8 to 11 year olds)
Monday 23 August to Friday 27 August (12 to 15 year olds)
Participant
First name Surname
Address
Postcode
Date of birth Age at time of camp
Parent/Guardian
First name
Address
Surname
Postcode
Telephone number (day)
Mobile Email
Medical details
Doctors name Doctors telephone number
Does your child have any medical conditions/allergies we need to be aware of?
Yes No
If yes, please provide details below (including medication)
Does your child have any disabilities that we would need to take into consideration when
planning these sessions?
Yes No
If yes, please provide details
Form continued overleaf...