Holiday Programmes

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?:
(you can include contact details for your child's doctor)

Have you attended our Fun Factory programmes before?
Yes
No

Sessions attending

Week 1

Week 2

Week 3

Week 4

General comments
(is there anything else you would like to tell us?)

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