GBCH School Holiday Programme Enrolment Form
1st Child’s Name …………………………………………………………………………
Date of birth ……………………….Age……………………………..
2nd Child’s Name ………………………………………………………………………..
Date of birth ……………………….Age……………………………..
3rd Child’s Name ………………………………………………………………………..
Date of birth………………………..Age……………………………..
Address …………………………………………………………………………………………………… ……………………………………………………………………………………………………
Name of Parent/Guardian…………………………………………………………………….
Phone Number (hm)………………….. (Wk)…………………….. (Mob)……………………
Email………………………………………………………………………………………………
First emergency contact person......
Phone Number (hm) ……………….. (Wk) …………………………. (Mob) …………………
Second emergency contact person…………………………….
Phone Number (hm)…………….. (Wk)……………………(Mob)……………………
Does your child have any cultural or dietary needs we should be aware of? Yes/No
If you answered yes, please state:
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Does your child suffer from any known medical conditions or allergies? Yes/No
If you answered yes, please state: ………………………………………………………………………………………………………
Is your child on any medication (including self administered) Yes/No
Please note medication must be clearly labeled with the child’s name, time & amount of each dosage. Please complete details of medication and dosage on the medical consent form. Medical consent form received Yes/ No
Will your child be collected from the centre by you? Yes/ No
People authorized to collect your child/ren from the centre
(Name and contact number please)
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Please list any other information you think we may need to know:
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Bookings: Please write in the date and times requested for each day
Times & Daily Fees
Before care: 8am to 9am $3.00
Day Session: 9am to 3pm $20.00
After Care: 3pm to 5.30pm $6.00
Monday 9/7 / Tuesday 10/7 / Wednesday 11/7 / Thursday 12/7 / Friday 13/7Time: / Time: / Time: / Time: / Time:
Monday 16/7 / Tuesday 17/7 / Wednesday 18/7 / Thursday 19/7 / Friday 20/7
Time: / Time: / Time: / Time: / Time:
PLEASE CHOOSE YOUR DAYS CAREFULLY AS NO REFUNDS CAN BE GIVEN ONCE YOUR PLACE HAS BEEN CONFIRMED IN THE PROGRAMME.
PLEASE MAKE SURE TO READ THE FOLLOWING AND SIGN BELOW:
*TRIP PERMISSION
I give permission for my child to attend this Holiday Programme including day trips and walks away from the centre and so not hold the programme liable for any incidents (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 Community House’s emergency policy to get my child the appropriate attention.
*PHOTOGRAPHY PERMISSION
As part of our School Holiday Programme the Green Bay Community House occasionally uses photography. We would like your permission to photograph your child/ children for possible inclusion in our publications, website and other publicity material. The image(s) will remain the property of Green Bay Community House and will be used for the designated purpose of promoting Green Bay Community House School Holiday Programme.
*(PLEASE CIRCLE ONE) I agree / Do not agree to having my child photographed while attending the School Holiday Programme
The information collected on this form is for administration purposes and to send information on the community house activities. It may be viewed by CYF and Ministry of Social Development staff as part of the Programme approval process. 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 Green Bay Community House 1 Barron Drive Green Bay.
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Signature of Parent/Guardian Date