Glen eden community house
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- DOES YOUR CHILD SUFFER FROM ANY KNOWN MEDICAL CONDITIONS
- Please complete details of medication and dosage on the Medical Consent Form
- WILL YOUR CHILD BE COLLECTED FROM THE CENTRE YES / NO
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GLEN EDEN COMMUNITY HOUSE APRIL 2016 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................................................................................................................ ............................................................................. Postcode ………………………... NAME OF PARENT / GUARDIAN/ CAREGIVER ................................................. PHONE NUMBER.................................... WORK.................................................... MOBILE ………………………………. EMAIL ……………………………………………………………………………… SECOND EMERGENCY CONTACT PERSON........................................................................ PHONE NUMBER HOME................................ WORK........................................... MOBILE ……………………………………… DOES YOUR CHILD SUFFER FROM ANY KNOWN MEDICAL CONDITIONSYES / NO (Please circle) If you answered yes please state the condition ............................................................................................................................... IS YOUR CHILD ON ANY MEDICATION YES / NO (Please circle) Please note medication must be clearly labeled with the child’s name, time and amount of each dosage. Please complete details of medication and dosage on the Medical Consent Form……………………………………………………………………………………… WILL YOUR CHILD BE ADMINISTERING THIS MEDICATION THEM SELF YES / NO (Please circle) WILL YOUR CHILD BE COLLECTED FROM THE CENTRE YES / NOI GIVE PERMISSION FOR MY CHILD/REN TO WALK TO AND FROM THE PROGRAMME YES / NO PEOPLE AUTHORIZED TO COLLECT YOUR CHILD/REN FROM THE CENTRE (Name and contact phone number please)............................................................................................................................... ................................................................................................................................ ……………………………………………………………………………………. PLEASE LIST ANY OTHER INFORMATION YOU THINK WE MAY NEED TO KNOW ...................................................................................................................................
Plus surcharges for April 2016 as follows: Tuesday 19 April Lopdell House $10.00 Friday 22 April MOTAT $15.00 Friday 29 April Mini Golf and Lunch $25.00
PERMISSION SLIP FOR TRIP APRIL 2016 PROGRAMME Due to low enrolments the children will be transported in 2 Vans or 1 Van and a staff Vehicle I give permission for..............................…………………………………… to go on a day trip to: Lopdell House - Titirangi on Tuesday 19th April 2016 Could all children be at the programme by 9.00am as we will be leaving by 9.15am MOTAT – Pt Chevalier on Friday 22 April 2016 Could all children be at the programme by 9.00am as we will be leaving by 9.15am Mini Golf and McDonalds Lunch – New Lynn on Friday 29 April 2016 We will be leaving at 10.15am .Please complete the below Order form McDonalds Menu Lunch Order: Please tick one item from each list:
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. All children will be transported to trip day venues in either a bus or Van ……………………………………………………………………………………….. SIGNATURE OF PARENT/GUARDIAN/CAREGIVER DATE The information collected on this form is for administration purposes and to send information on community house activities and future out of school care 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 Glen Eden Community House Office13 Pisces Road GLEN EDEN. As part of the programme photographs or video’s make is taken these images remain the ownership of the Community House and may be used for advertising purposes. Please advise the Manager if you do not want your child/rens images used. Some of these images may be used on our Facebook page. 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: Programme Fees Due $ Plus Surcharges Charges $ Total Amount Due $ Amount Paid Date Receipt Number Amount Paid Date Receipt Number Amount Paid Date Receipt Number WINZ Declaration _____________ Date Entered ___________ WINZ New Subsidy _____________ Date Entered ___________ Cash Manager _____________ Date Entered ___________ Email Database _____________ Date Entered ___________ Master List _____________ Date Entered ___________ SHP Enrolment Form Updated 2014 Download 54.28 Kb. Share with your friends:
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