After school care

Fields marked (*) are required

Child's Name:*

Birthdate:*

Address:*

School

Next of Kin / Emergency contact details

Name:*

Relationship (eg "parent"):*

Home Phone:*

Mobile Phone:

Email: (If supplied you will receive a copy of your form as a receipt)

WINZ client number if you have one

Medical information

Are there any medical conditions or allergies we should know about?:

Sessions attending (weekdays in school terms only)

Please tick if you do not wish to have photos of your child included in displays or used for promotional purposes.