Point Chevalier Community Centre Inc.

You may download a PDF copy of this enrolment form right here.

Please use that version for printing and signing. (If you don’t already have a hard copy.)

The form has recently changed for Jan 09 so please use the PDF copy.

Please note: This version below is a preview only and is not for printing.  Please print the linked PDF version or collect a hard copy from the Centre itself.

Point Chevalier Community Centre Inc.
SCHOOL HOLIDAY PROGRAMME ENROLMENT FORM

Child/ren’s Names:______________________________________
Address: _____________________________________________
Date of Birth & Age: _______________________________________
Parent/s/Guardian Names: ______________________________________________
Phone: (Hm) ____________ Mob: ____________Phone: (Wk) _____________
Phone: (Hm) ____________ Mob: ____________Phone: (Wk) _____________
Email: ____________________________

People authorised to collect your child (other than yourself):
1. __________________ Phone: __________________
2. __________________ Phone: __________________
3. __________________ Phone: __________________
Are there any circumstances which we should be aware of in relation to your child, e.g. anybody you do not wish to collect your child from the School Holiday Programme:
___________________________________________________________________________
Please provide two people (other than yourselves) to call in case of an emergency:
Name: ____________________________________________ Phone: __________________
Name: ____________________________________________ Phone: __________________
Health Matters/Medical Conditions:
Family Doctor: ______________________________________ Phone: __________________
Please list any allergies, dietary restrictions, disabilities/impairments etc:
______________________________________________________________________________
______________________________________________________________________________
State dates and time your child/ren will be attending including any before & after care:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Parent/Guardian
I give my child/ren permission to attend excursions planned in the programme. I give permission to have my child/ren administered first-aid if necessary. If required my child/ren will be taken to Pt Chevalier Medical Centre for on-site days and to the nearest medical centre on excursion days – I accept responsibility for any costs involved. Every care is taken to provide proper supervision of all children.

We will not be responsible for lost property and parents may be liable for damage to property caused by their child/ren. All information given to us is confidential.

Signature of Parent/Guardian: _________________________________ Date: ________

If you have any complaints, in the first instance please approach the Programme Supervisor (or Programme Co-ordinator if preferred). A complaints procedure policy is on file if you wish to view it.