Breakaway Holiday Programme January 2020

Participant

First name

Surname

Age (in years only) MUST BE AGED BETWEEN 11-18 TO ATTEND

Date of birth - MUST BE AGED BETWEEN 11-18 TO ATTEND

Male/Female

Male

Female

Ethnicity

Medical

Medical Details

List all allergies/asthma/serious illnesses/injuries or special dietary requirements or issues for your child/children

Current Medication

Description of any current medications and instructions for administering to your child/children, if required.

Attendance

Please indicate which day(s) your child will be attending and WHICH PROGRAMME - WHANGAREI OR KAIKOHE

Dates of attendance. e.g Monday 11th - Friday 15th January, Monday 18th - Friday 22nd January 2021 (WHANGAREI) Monday 18th - Friday 22nd January 2021 (KAIKOHE)

Parent/Caregiver details

Name *

Phone number *

Email *

Name *

Phone Number *

Collection instructions

Person(s) not authorised to collect your child, or special instructions regarding collection and access to your child.

Permissions and Acknowledgements

Photographs *

Yes

I give permission for my child/children to be photographed during the Holiday Programme activities. Please note that if you give permission for your child to be photographed, these photographs may be used for reporting purposes; advertising and promotional material.

Acknowledgements

IMPORTANT: To maintain the integrity of the service and the privacy of all enrolled on the programme, mobile phones, cameras or other hand held electronic devices by participants are NOT permitted. If you require your child to have access to a mobile phone, these should be handed in to the programme coordinator at the beginning of each day and these will be returned to your child at the end of each day. Additionally, all children must bring lunch and a drink bottle every day.

We acknowledge this *

Yes

Privacy Act

The information that you have supplied is necessary for the safe and effective operation of this Break Away Holiday Programme. All personal information will be kept confidential. You are welcome to review information pertaining to your child’s enrolment at any time.

Should any of the above details change, it is essential that this BREAKAWAY programme is made aware of these changes.

I confirm all these details are correct *

Yes

Your name

Where did you hear about Breakaway? *

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