TITIRANGI COMMUNITY HOUSE
SCHOOL HOLIDAY PROGRAMME ENROLMENT FORM:
Monday9th to Friday20thJuly 2018
FULL Name of Child / Date of Birth1 / M / F
2 / M / F
3 / M / F
4 / M / F
Ethnic origin of child/ren Please tick
NZ European / Niue / Fijian / IndianOther European / Tongan / Other Pacific Is / Other Asian
NZ Maori / Cook Is Maori / SE Asian / Other
Tokelauan / Samoan / Chinese
Iwi affiliation if NZ Maori is ticked. Up to 3 Iwi affiliations may be identified
Parent/caregiver: (please circle)Name:
Relationship:(to child)
Address: (street number & name)
(suburb) (postcode)
Home phone: Work phone:
Mobile number:
Email address:(please write clearly)
EMERGENCY CONTACT DETAILS: At least two are required (not a Guardian)
First Emergency Name:Relationship:(to child)
Mobile number:
Second Emergency Name:
Relationship:(to child)
Mobile number:
Pick up and drop off Information:
Will your child/ren be walking to or from the programme Yes / No
(Child’s name)
______
If yes:
What time would we expect your child/ren to arrive at the programme: time of arrival
What time do we sign your child/ren out of the programme: time
People Authorised to collect your Child/ren
Name:
Relationship: (to child) Mobile number:
Name:
Relationship: (to child) Mobile number:
Name:
Relationship: (to child) Mobile number:
DOES YOUR CHILD/CHILDRENSUFFER FROM ANY KNOWN MEDICAL CONDITIONS YES / NO.
If you answered yes, please state the condition for each child.
1)Child’s Name: ……………………………………………………………………………………………..…..……
Condition: ...... ……………………......
2)Child’s Name: ……………………………………………………………………………………………..…..……
Condition: ...... ……………………......
3)Child’s Name: ……………………………………………………………………………………………..…..……
Condition: ...... ……………………......
4)Child’s Name: ……………………………………………………………………………………………..…..……
Condition: ...... ……………………......
IS YOUR CHILD ON ANY MEDICATION YES / NO? Child’s Name:………………………………….….…..….
Medical Consent Form Completed YES / NO? Medical Records Updated: YES / NO
Office Use Only
WILL YOUR CHILD BE ADMINISTERING THIS MEDICATION THEMSELF YES / NO
Parents Signature………………………………………………………………………………………
Does your child/children have any behavioural and /or learning difficulties?YES / NO
If you answered yes, please state below the specific behavioural or learning issue for each child.
Note: Stating your child’s behaviour problems will not prevent your child attending, but staff’s awareness of potential issues will ensure the safety of your child, themselves and other children.
This will enable staff to be more supportive of your child.
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If there are any personal issues you would like to discuss in confidence, please do not hesitate to ring our supervisor Nanette on 021549430 or 09 8169163.
PLEASE LIST ANY OTHER INFORMATION YOU THINK WE MAY NEED TO KNOW.
E.g. Food or other allergies.
...... ………………………………….…….
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As we have children in the programme with severe allergies, please do not pack any peanut butter products
We support building healthier communities together.
Visit for healthy meal options and ideas
ARE YOU ENROLLING YOUR CHILD FOR THEFULL2WEEK PROGRAMME YES / NO
If NOPLEASE TICK THE DAYS AND TIMES REQUIRED
Include your child/ren’s name if you have more than one child attending different sessions
JULY 2018First Week / Day Session
9am to 3pm / Before Care
Starts 8am
$2.50 / 30min
Or part thereof / After Care
Starts 3pm
$2.50 / 30min
Or part thereof / TOTAL
PER DAY
Monday 09 July / $30 / Time in / Time out
Tuesday 10 July / $30 / Time in / Time out
Wednesday 11 July / $35 / Time in / Time out
Thursday 12 July / $30 / Time in / Time out
Friday 13 July / $35 / Time in / Time out
JULY 2018
Second Week / Day Session
9am to 3pm / Before Care
Starts 8am
$2.50 / 30min
Or part thereof / After Care
Starts 3pm
$2.50 / 30min
Or part thereof / TOTAL
PER DAY
Monday 16 July / $30 / Time in / Time out
Tuesday 17 July / $30 / Time in / Time out
Wednesday 18 July / $35 / Time in / Time out
Thursday 19 July / $30 / Time in / Time out
Friday 20 July / $30 / Time in / Time out
Total Amount Due $______
We prefer payment by Direct deposit:
Titirangi Community House School Holiday Programme Bank Account
ASB 12 - 3100 - 0107888 - 02
PLEASE NOTE: All previous balances must be cleared before we can enroll child/ren in further School Holiday Programmes
Custodial InformationAre there any custodial arrangements concerning your child/ren Yes / No
If yes please give details of custodial arrangements or court orders
A Copy of the Court Orders are required to kept on file
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I give permission for any photographs or videos to be taken of my child/children who attend this Holiday Programme at the Titirangi Community House, including trips days away from the Community House. These may be used in our newsletters and on our website.
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SIGNATURE OF PARENT/GUARDIAN/CAREGIVER
...... ………………………………....
DATE
I give permission for my child to attend this Holiday Programme including day trips away from the centre and do not hold the programme liable for any accidents (other than those arising from clear negligence) to my child in the programme care. In the event of an emergency, I give permission for the programme staff to carry out the centre’s emergency policy to get my child the appropriate attention, i.e. in the School Holiday Programme Supervisors private motor vehicle.
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SIGNATURE OF PARENT/GUARDIAN/CAREGIVER
...... ………………………………....
DATE
NB. The proposed activities may change at short notice at the discretion of the School Holiday Programme Supervisor.
This may also include trips to Titirangi Primary School, Lopdell House and supervised walks.
The information collected on this form is for administration purposes and to send information on community house activities and future school holiday programmes. You have the right to access and correct your information, subject to the restrictions in the Privacy Act 1993. This information will be held at the Titirangi Community House Office 500 South Titirangi Road, Titirangi.
TITIRANGI COMMUNITY HOUSE
SCHOOL HOLIDAY PROGRAMME
WINZ Subsidy Form – Please return a copy of the proof of receipt from WINZ within one week of the date of this form being completed.If this is not received, you will be expected to pay prior to the programme commencing.
______
Office use only:
Fees Due School Holiday Programme $
Fees Due Before care $
Fees Due Aftercare $
Total Amount Due $______
WINZ Subsidy Form CompletedYes / NoDated:
Invoiced$Date:Invoice Number:
Amount Paid$Date:Receipt Number:
Amount Paid$Date:Receipt Number:
Amount Paid$Date:Receipt Number:
Amount Paid$Date:Receipt Number:
School Holiday Programme Enrolment Form Z:\SHP\SHP Forms & Resources\SHP Enrolment Form