Enrolment Form

Enrolment Form
Which Programme are you enrolling for? *

Holiday Programme Before/After school
How many children are you enrolling? *

1 2 3
CHILD NAME 1: *

First Name Last Name
Date of Birth *

Day Month Year
Date
Age
e.g. 8
Gender *

Male Female
Ethnic Group

New Zealand European Maori Samoan Tongan
School Attended *
CHILD NAME 2: *

First Name Last Name
Date of Birth *

Day Month Year
Date
Age
e.g. 8
Gender *

Male Female
Ethnic Group

New Zealand European Maori Samoan Tongan
School Attended *
CHILD NAME 3: *

First Name Last Name
Date of Birth *

Day Month Year
Date
Age
e.g. 8
Gender *

Male Female
Ethnic Group

New Zealand European Maori Samoan Tongan
School Attended *
School Attended
Parent / Caregiver Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City

Post Code
Mobile Number *
Phone #2
Email *
example@example.com
Cell Phone *

Area Code Phone Number
Work Number

Area Code Phone Number
Emergency Contact 1 *

First Name Last Name
Relationship to Child
Emergency Contact Phone Number *
Emergency Contact Email
Emergency Contact 2 *

First Name Last Name
Emergency Contact Phone Number *
Emergency Contact Email
Emergency Contact Phone Number

Area Code Phone Number
Emergency Contact Phone Number

Area Code Phone Number
Emergency Contact Cell *

Area Code Phone Number
Emergency Contact Cell *

Area Code Phone Number
Who is authorised to pickup from the activity?
Name of anyone else who can pick up your child
Name of any adults not authorised to pick up your child?
Are there any known allergies?

Yes No
Is there an allergy to bee stings?

Yes No
Does your child suffer from asthma?

Yes No
Any other medical conditions or health problems?

Yes No
Is your child on medication?

Yes No
Instructions/Special Needs
If there are any health conditions, behaviour, allergy, cultural or dietary requirements, please list them here.
Note: written consent is required if medication needs to be given while participating in the programme.
Medical Centre Name *
Medical Centre Phone *
Doctor Name
Will you be applying for OSCAR subsidy?
Is there any additional information that would help staff ensure the physical and emotional well-being of your child?
Permissions:
I understand that I need to sign my child in/out of the programme *

Yes No
I give permission for sun block to be applied to my child *

Yes No
I agree to my child being transported when required *

Yes No
I give permission for my child to be photographed (only for website/social media) *

Yes No
Note: On the booking site, you will be required to login/create account to save your dates.
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Enrolment Form

Permissions: