Your Name *

Your Name

First Name

Last Name

Contact Number *

Email Address *

Child's Name *

Child's Name

First Name

Last Name

Child's Date of Birth *

Child's Date of Birth

YYYY

Relation to child *

Post Code *

Mother / Father's Name

Or other person to use as Next Of Kin

First Name

Last Name

Does the child have any allergies?

Does the child have any learning difficulties?

Does the child have any physical or mobility difficulties?

How did you hear about Sensory Land? *

e.g. Hoop, Flyer, Facebook group

How do you rate this class out of 5? *

1 is the worst - 5 is the best

Do you have any feedback?