After School CHILD ONE'S DETAILS Child's Name (full name): Gender: MaleFemale Age: ---91011121314 Date of birth: School: Year at School 2015: ---Year 6Year 7Year 8Year 9 Medication: Any medication required during programme is to be provided by parent/caregiver Dosage: Any food allergies? YesNo Programmes: Please select the days and programmes you wish your children to attend AfterSchool (3-5:30pm) Please tick days attending $20 per day MonTueWedThur Start Date Intermediate children (10 year olds & older only): I give permission for the child above to sign them self out at: CHILD TWO'S DETAILS Child's Name (full name): Gender: MaleFemale Age: ---91011121314 Date of birth: School: Year at School 2015: ---Year 6Year 7Year 8Year 9 Medication: Any medication required during programme is to be provided by parent/caregiver Dosage: Any food allergies? YesNo Programmes: Please select the days and programmes you wish your children to attend AfterSchool (3-5:30pm) Please tick days attending $25 per day MonTueWedThur Start Date Intermediate children (10 year olds & older only): I give permission for the child above to sign them self out at: CHILD THREE'S DETAILS Child's Name (full name): Gender: MaleFemale Age: ---91011121314 Date of birth: School: Year at School 2015: ---Year 6Year 7Year 8Year 9 Medication: Any medication required during programme is to be provided by parent/caregiver Dosage: Any food allergies? YesNo Programmes: Please select the days and programmes you wish your children to attend AfterSchool (3-5:30pm) Please tick days attending $25 per day MonTueWedThur Start Date Intermediate children (10 year olds & older only): I give permission for the child above to sign them self out at: PARENT/CAREGIVER'S DETAILS Parent/Caregiver 1 Name: Relationship to child: Home phone number: Work phone number: Cellphone number: Email: Address: Suburb: Parent/Caregiver 2 (if applicable) Name: Parent/Caregiver 2 Relationship to child: Home phone number: Work phone number: Cellphone number: Email: Address: Suburb: EMERGENCY INFORMATION (please provide two contacts different from above) Emergency contact person 1: Relationship to child: Emergency daytime phone: Emergency cellphone: Emergency contact person 2: Relationship to child: Emergency daytime phone: Emergency cellphone: OTHER INFO Additional people authorised to collect my child: People who may not collect my child (possibly due to custodial issues): Will you be applying for WINZ? YesNo Any other comments: AGREEMENT / SUBMISSION I Have Read And Accept the Terms And Conditions (After School Only ). Please check you have filled in all fields and then click "submit" button or "clear" to start over. You will receive a confirmation email followed by a letter.
