Aanmelding - Sport en spel NSO Leeuwenbergh ‘Simba’

EN | NL

Registration for Sport en spel NSO Leeuwenbergh ‘Simba’

Requested childcare

Voor definitieve registratie berekenen we éénmalig € 25,- inschrijfgeld per kind. U kunt dit betalen ten name van Sportcentrum Leeuwenbergh op Rabobank op IBAN NL59 RABO 0300 3862 65 onder vermelding van uw naam.

Startdate*

Remark

Child

You will be able to register another child after submitting the first registration

Initials*
First name*
Last name prefix
Last name*
Phonenumber (Incase of emergency)*

Date of birth*
Estimated date of birth / Not yet born
Nationality*
Spoken language*
Gender*
Citizen number (BSN)*

Nickname*
School/Classroom*
Allergies*
Medication*
Medical notes
Health insurance*
Health insurance policy number*
May be picked-up by

Doctor/General practitioner*
Dentist*
If your Doctor/General practitioner/Dentist is not mentioned in the list, can you please write them in the remark field above?

Consent questions

Please fill with Yes or No to what applies

Heeft uw kind een zwemdiploma?*
Mag uw kind samengevoegd worden in een andere basisgroep?*
Mag uw kind op de foto voor intern gebruik?*
Mag uw kind op de foto voor extern gebruik?*
Mag uw kind mee op uitje?*

Parent/Guardian 1 (Who will receive the invoices)

Title*
Initials*
Firstname
Last name prefix
Last name*
Date of birth*
Nationality*
Citizen Number (BSN)*
Streetname*
House number*
House number extension
Postalcode (numbers)*
Postalcode (characters)*
City*
Country*
Phone number (Home)
Mobile phone number*
Phonenumber (work)
E-mail address*
IBAN*
BIC/SWIFT code (if applicable)

Parent/Guardian 2

Title
Initials
Firstname
Last name prefix
Last name
Date of birth
Nationality
If you do not enter an address here, the address of parent/guardian 1 will be automatically taken over.
Streetname
House number
House number extension
Postalcode (numbers)
Postalcode (characters)
City
Country
Phone number (Home)
Mobile phone number
Phonenumber (work)
E-mail address
BIC/SWIFT code (if applicable)

Emergency person

Title*
Initials*
First name*
Last name prefix
Last name*
Relation*

Street*
House number*
Postalcode (numbers)*
Postalcode (characters)*
City*
Mobilephone number*

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