Registration Form Monday 18 th April Friday 22 nd



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Sir Peter Blake MERC School Holiday Programme Registration Form

Monday 18th April - Friday 22nd April and Tuesday 26th April - Friday 29th April 2016

NOTE - Our programme is designed for children aged between 7 – 13years (inclusive). We regret that due to the nature of the programme we are unable to accept children outside of this range. Please complete one form per child.



Participant’s Name:




Age:




Address:




School:




School Year:




Parents Name(s):




Home Phone:




Family e-mail:




Primary Contact:




Telephone:




If a child becomes ill it is vital that we are able to contact someone. Please also provide mobiles where appropriate.

Alternative Contact:




Telephone:




Doctor:




Telephone:




IMPORTANT – The following information is critical if we are to care for your child. Please provide additional details in the box on the right where appropriate & continue on an additional sheet if necessary.

Is participant generally a healthy child?

No/Yes

Click here to enter text.

Are tetanus injections up to date?

No/Yes

May child be given a panadol tablet, if required?

No/Yes

Does participant require regular medication?

No/Yes

Click here to enter text.

Does participant have any allergies, for example to medication, food, bee stings etc?

No/Yes

Click here to enter text.

Does participant have any medical conditions such as diabetes, heart abnormalities, epilepsy or asthma?

No/Yes

Click here to enter text.

Does participant have any physical or intellectual disabilities?

No/Yes

Click here to enter text.

Are there any other concerns that might affect the child’s active participation in activities, for example recent ear infections, back problems, fear/anxiety?

No/Yes

Click here to enter text.

While it is NOT a requirement for participation, please indicate the following:

Participant can confidently swim 25m.

No/Yes

Click here to enter text.

I would like to be added to the school holiday program database

No/Yes

I approve of my child attending MERC and they are able to participate in all presented activities. In the event of an accident or illness I authorise MERC to obtain any such medical assistance as considered appropriate by MERC staff. MERC staff will provide full safety briefings to all participants. It is the responsibility of participants to follow these instructions to minimise risk of injury.

Name:

(Parent / Caregiver)






Date:




Costs - $35 per day from 8.30am until 4.30pm or $5 extra per day from 7.30am until 6pm. Sessions begin at 9am and end at 4pm. Extended pickup hours are available from 7.30am to 6pm where the kids will be supervised by an instructor. Pay for 5 days or more and receive a 10% discount.

 Regular session 8.30am – 4.30pm  7.30am - 6pm  7.30am - 4.30pm  8.30am - 6pm



Please book my child for the following days:

I will be paying by:

Monday 18th April 2016

No Programme

 Cash (in person)

Tuesday 19th April 2016

Tuesday 26th April 2016

Cheque (payable to MERC)

Wednesday 20th April 2016

Wednesday 27th April 2016

 EFTPOS (in person)

Thursday 21st April 2016

Thursday 28th April 2016

 Internet Banking *(see below)

Friday 22nd April 2016

Friday 29th April 2016

 Credit Card (add $4.50 processing fee)

* Details for Internet Banking – Sir Peter Blake MERC, ASB Browns Bay, 12-3080-0084905-00

Please return completed form and full payment to

I will be paying by:

MERC, PO Box 35-119, Browns Bay, North Shore 0753

 Cash (in person)

1045 Beach Road, Long Bay, North Shore

 Cheque (payable to MERC)

Fax: (09) 473 1945 Tel: (09) 473 0714 ext. 201

 EFTPOS (in person)

E-mail: office@merc.org.nz

 Internet Banking *(see below)

www.merc.org.nz http://www.facebook.com/sirpeterblakemerc

 Credit Card (add $4.50 processing fee)


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