Registration Form Monday 18 th April Friday 22 nd

Download 29.17 Kb.

Date	31.07.2017
Size	29.17 Kb.
	#25271

Sir Peter Blake MERC School Holiday Programme Registration Form

Monday 18^th April - Friday 22^nd April and Tuesday 26^th April - Friday 29^th 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	Click here to enter text.

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 18^th April 2016	No Programme	Cash (in person)
Tuesday 19^th April 2016	Tuesday 26^th April 2016	Cheque (payable to MERC)
Wednesday 20^th April 2016	Wednesday 27^th April 2016	EFTPOS (in person)
Thursday 21^st April 2016	Thursday 28^th April 2016	Internet Banking *(see below)
Friday 22^nd April 2016	Friday 29^th 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)

Directory: wp-content -> uploads -> 2014
2014 -> For want of a nail
2014 -> Stop Militarizing Law Enforcement Act of 2014
2014 -> Ihbb asian Championships 2014 middle school bowl Round 4 First Quarter
2014 -> Ihbb european Championships 2014 Bowl Round 4 First Quarter
2014 -> International History Bee and Bowl 2013-14 Asian Division Question Set Bowl Round Six
2014 -> United states patent and trademark office
2014 -> Coffs harbour eisteddfod vocal syllabus
2014 -> Listen News Programs Schedule pledge now
2014 -> Slow club announce third album complete surrender

Download 29.17 Kb.

Share with your friends: