Enrolment Form

Enrolment Form
Which Programme are you enrolling for?*

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

123
CHILD NAME 1:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Age
e.g. 8
Gender*

MaleFemale
Ethnic Group

New Zealand EuropeanMaoriSamoanTonganOther
School Attended*
CHILD NAME 2:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Age
e.g. 8
Gender*

MaleFemale
Ethnic Group

New Zealand EuropeanMaoriSamoanTonganOther
School Attended*
CHILD NAME 3:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Age
e.g. 8
Gender*

MaleFemale
Ethnic Group

New Zealand EuropeanMaoriSamoanTonganOther
School Attended*
School Attended
Parent / Caregiver Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
Work Number

Area CodePhone Number
Emergency Contact 1*

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

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

Area CodePhone Number
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Cell*

Area CodePhone Number
Emergency Contact Cell*

Area CodePhone 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?

YesNo
Is there an allergy to bee stings?

YesNo
Does your child suffer from asthma?

YesNo
Any other medical conditions or health problems?

YesNo
Is your child on medication?

YesNo
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*

YesNo
I give permission for sun block to be applied to my child*

YesNo
I agree to my child being transported when required*

YesNo
I give permission for my child to be photographed (only for website/social media)*

YesNo
Note: On the booking site, you will be required to login/create account to save your dates.
Should be Empty:

Enrolment Form

Permissions: