on-line application form

Would you please consider the child named below to be included on one of your holidays.

1.I/We understand that all the Groups are attended by a Doctor, Nurses and the necessary auxilary staff to meet the child's needs.

2.I/We also understand that candidates' priorities will be assessed by a medical committee whose decision will be final.

3.That any offer of a place will be subject to availability of funds.

4.That the NHF reserve the right to cancel or alter stated arrangements at short notice

5. Parents and Guardians will NOT be permitted to accompany their child.

You must give permission for the Doctors and schools in charge of our child's care, to be approached for relevant medical, educational and social information in order that we may meet your child's needs.

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I/We agree that all necessary relevant information may be obtained:
Yes
Child's Full Name:
Sex:
Male Female
Child's Address:
Post Code:
Age:
Date of Birth (dd/mm/yy):
Religion:
Nature of Illness:
Parent(s)/Guardian FULL Name:
Parent(s)/Guardian Address:
Parent(s)/Guardian Post Code:
Parent(s)/Guardian Tel No:
Parent(s)/Guardian E-mail:
FULL name of your child's Doctor (GP):
Doctor's (GP) Address:
Doctor's (GP) Post Code:
Doctor's (GP) Tel No:
Consultant's Name:
Hospital Address:
Hospital Post Code:
Hospital Tel No:
Child's Hospital Reference Number (if known):
Name of school attended:
School address:
School Post Code:
School Tel No:
Social Workers name and contact telephone No:
Has your child ever benefited or applied for a holiday with another organisation?:
Yes No
Has your child ever visited Florida, USA?:
Yes No
Date of Application (dd/mm/yy):