EQUIPPERS HOLIDAY PROGRAMME ENROLMENT FORM

NO CHILDREN BOOKED UNTILL THIS FORM RECEIVED

This form is to be filled out on enrolment and updated for each programme. One form per family is needed.

Children’s Information

Managed by: Equippers Holiday Programme Staff

Name / Gender / Age
M / F
M / F
M / F
M / F
Parent/Caregivers Information
Mother’s Name: / Mobile:
Place of Employment: / Work Phone:
Father’s Name: / Mobile:
Place of Employment: / Phone:
Caregiver’s Name: / Mobile:
Agency: / Email for accounts:
PLEASE PRINT CLEARLY
Home Address:
Home Phone: / Email:
PLEASE PRINT CLEARLY
Emergency Contact
1st Emergency Contact Name:
Relationship (Uncle, Grandparent, Parent etc)
Work Number: / Mobile:
Home Number:
2nd Emergency Contact Name:
Relationship (Uncle, Grandparent, Parent etc)
Work Number: / Mobile:
Home Number:
All Persons Authorised to Collect Children (Incl main caregivers)
Name / Relationship
Medical Information
Name of Doctor: / Contact Number:
Medical Conditions/Allergies or Medication Required / Y / N
If yes please provide further information (food/animal/medical allergies, special needs, behavioural issues etc)
Our Medical Consent Form Filled and Signed for Staff to administer medication: Y / N
Funding
Are you applying for WINZ Subsidies / Y / N / Forms Filled / Y / N
Other: (Eg Studylink/OHF/MVC)
Please supply all information / Y / N / Forms Filled / Y / N

If you circle yes for WINZ subsidy, Oscar Subsidy Declaration forms must be supplied upon enrolment and completed forms dropped into Work & Income before enrolment is confirmed.

Week One

Day / Date / Start Time / Finish Time
Monday / 16/04/18
Tuesday / 17/04/18
Wednesday / 18/04/18
Thursday / 19/04/18
Friday / 20/04/18

Week Two

Day / Date / Start Time / Finish Time
Monday / 23/04/18
Tuesday / 24/04/18
Wednesday / 25/04/18 / CLOSED
Thursday / 26/04/18
Friday / 27/04/18

Disclosure of Risk:

I understand there are risks involved when the above participant is indoors or venturing outdoors that could result in injury to participants and/or their property.

The managers of this programme use risk management with all activities to minimize risk. In the case of injury, loss or damage to property I release the Oasis Trust from any liability for damages, loss or injury that can only be made against The Accident Rehabilitation and Compensation and Compensation Insurance Corporation.

I am aware of the casual outings procedure for the holiday programme and I am happy for my child to take part when he/she attends. I give permission for my child/ren to take part in large group outings and day outings.

Signature:Date:

Non Attendance:

I understand that 24hours notice of a child’s absence needs to be given to the programme organiser. I acknowledge that there will be a full days charge to my account if there has been a nil attempt of communication to the programme. Charge can be avoided if communication to the programme organiser has been made and the situation discussed. (Further information on this topic will be in the parent information form)

Signature:Date:

Photos and Image:

I understand that there is photo and video recording on the programme for the purposes of promotional materialsrelating only to the programme. I give permission for my child/children to be photographed and/or recorded for these purposes only.

Signature:Date:

Medical Treatment Consent:

I give permission for Holiday Programme authorized staff and volunteers to obtain emergency medical, hospital or ambulance assistance at any time they deem necessary. I understand that every effort will be made for me to be notified before instituting such procedures. I acknowledge that I will be liable for any medical/hospital/ambulance expenses incurred in the treatment of my child/ren. I also understand that while every reasonable precaution will be taken to ensure the protection of my child/ren) I hereby release and hold blameless Holiday Programme authorized staff and volunteers from any and all liability in the event of any injury, accident or misfortune, damage or loss that may occur whilst present on this programme.

Signature:Date:

Accounts & Fees:

NEW ENROLMENT PRE PROGRAMME DEPOSIT

A $20.00 deposit is required per child on enrolment & confirmation of WINZ. For non WINZ, 50% of the total cost is required per child upon enrolment. Accounts for OSCAR@OASIS After School Care or Holiday Programme are due for payment within 7 days following a weekly Invoice. (Non-payment of accounts will be referred to a Collection Agency and recoverable costs for this service will be added to your account.)

Signature:Date:

Car Seats

I give permission for my child/ren (aged 5 & 6) to use NZ safety approved half booster seats when being transported in the vans. These seats are provided by Equippers Church Masterton.

Signature: Date:

Privacy Act 1993: The information that you have supplied is necessary for the safe and effective operation of the programmes at Equippers Church.

P.O. Box 954 Masterton Phone: 06-3788789 Email: