January 2025 Mt Cook Holiday Programme

Mt Cook January 2025

Lifepoint Church - 61 Hopper Street, Mount Cook
Student's Full Name:*

First NameLast Name
Student's Gender:*

MaleFemale
Student's Birthday*

DayMonthYear
Date
Student's School:*
Parent / Caregiver Full Name:*

First NameLast Name
Parent / Caregiver Phone Number*

Area CodePhone Number
Parent / Caregiver Email Address*
example@example.com
The following adult is authorised to pick up my child:*

First NameLast Name
How did you hear about us?*

Already a customerWord of mouthGoogle AdFacebook AdFlyerStreet SignageOther

Please select the programmes you wish to enrol in:*

Special Instructions
I consent to the use of any photographs or video recordings of my child on public social media platforms while participating in the Bricks4Kidz programs.*

YesNo
Should be Empty:

Mt Cook January 2025