(09) 521 0009
info@barfootstadium.co.nz
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Home
Upcoming Events
Venue Hire
Weddings
Events
Meeting Rooms
Sports
Documentation
What's Here
Futsal / Football
Basketball
Martial Arts
Volleyball
Ultimate Frisbee
Fitness and Health
Children's Activities
Preschool
After School
Holiday Programme
Children's Parties
Online Forms
Gallery
About Us
East City Community Trust
Management Team
Feedback
Our Partners
Contact Us
(09) 521 0009
Holiday Program Enrolment
Please complete the following form for holiday program enrolment
*
Indicates required field
Parent /Guardian Information
Full Name
*
Address
*
Phone (Daytime)
*
Phone (Evening)
*
Email
*
Child's Information
Full Name
*
D.O.B
*
dd/mm/yyyy
Gender
*
Male
Female
Commencement Date
*
dd/mm/yyyy
School Attended
*
Please tick the required days for the Holiday Club:
19th - 21 December
*
Wednesday 19th
Thursday 20th
Friday 21st
14th - 18th January
*
Monday 14th
Tuesday 15th
Wednesday 16th
Thursday 17th
Friday 18th
21st - 25th January
*
Monday 21st
Tuesday 22nd
Wednesday 23rd
Thursday 24th
Friday 25th
Please tick the required days for each Aftercare:
19th - 21st December
*
Wednesday 19th
Thursday 20th
Friday 21st
14th - 18th December
*
Monday 14th
Tuesday 15th
Wednesday 16th
Thursday 17th
Friday 18th
21st - 25th January
*
Monday 21st
Tuesday 22nd
Wednesday 23rd
Thursday 24th
Friday 25th
Family Doctor (Put NA if not available)
*
Family Doctor Phone
*
Health Record
*
Please specify allergies and ailments (e.g. asthma, bee stings, food, penicillin and epilepsy), medical conditions, and assistance required.
Medication (to be provided by parent/guardian)
*
Description of Medication
*
Dosage
*
Is this to be administered by the Holiday Programme Staff?
*
Yes
No
Is there any other information the programme should be aware of?
*
Emergency Contact 1
Full Name
*
Address
*
Phone (Daytime)
*
Phone (Evening)
*
Emergency Contact 2
Full Name
*
Address
*
Phone (Daytime)
*
Phone (Evening)
*
Other Authorised Adults to Pickup Children
Full Name
*
Phone Number (Home)
*
Phone Number (Work)
*
Phone Number (Mobile)
*
Relationship to Child
*
Other Authorised Adults to Pickup Children
Full Name
*
Phone Number (Home)
*
Phone Number (Work)
*
Phone Number (Mobile)
*
Relationship to Child
*
Terms and Agreement
*
I have read the terms & agreement and acknowledge that ECCT Staff will run the Holiday Programme.
View "
Terms and Agreement
" for Holiday Programme
Submit
