Full Intake Form for Children with Special Needs
ONLY government agencies for auditing purposes will have access to the below information
Student's Full Name
*
First Name
Last Name
Student's Birthday
*
-
Day
-
Month
Year
Date
Student's School
*
Parent / Caregiver Full Name:
*
First Name
Last Name
Parent's / Caregiver's Birthday
*
-
Day
-
Month
Year
Date
Parent / Caregiver Phone Number
*
Parent / Caregiver Email Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Emergency Contact Person Full Name:
*
First Name
Last Name
Second Emergency Contact Person Phone Number
*
Other people's name pick up the child if not the two names above:
Assistant Person's Name
*
First Name
Last Name
Assistant Person Phone Number
*
People's name NOT authorised to pick up the child:
Strengths and Interests:
*
(E.g., enjoys building complex LEGO models, loves storytelling, excels in creative thinking)
Known Triggers:
*
(E.g., loud noises, transitions, unfamiliar activities)
Preferred Calming Activities or Strategies:
*
(E.g., quiet reading time, sensory toys, deep breathing exercises)
Location would like to enrol
*
Hamilton Central Waikato Sport Fishing Club(499 Grantham Street, Hamilton Central)
Rototuna High School(56 Kimbrae Drive, Rototuna North)
Days would like to enrol （9am-4pm）:
***Full Week 1 : 22nd -26th Sep
1.Monday: 22nd Sep
2.Tuesday: 23rd Sep
3.Wednesday: 24th Sep
4.Thursday: 25th Sep
5.Friday: 26th Sep
***Full Week 2 : 29th Sep-3rd Oct
1.Monday: 29th Sep
2.Tuesday: 30th Sep
3.Wednesday: 1st Oct
4.Thursday: 2nd Oct
5.Friday: 3rd Oct
Early Drop-offs (from 8am):
Early Drop off Monday: 22nd Sep - $8
Early Drop off Tuesday: 23rd Sep - $8
Early Drop off Wednesday: 24th Sep - $8
Early Drop off Thursday: 25th Sep - $8
Early Drop off Friday: 26th Sep - $8
Early Drop off Monday: 29th Sep - $8
Early Drop off Tuesday: 30th Sep - $8
Early Drop off Wednesday: 1st Oct - $8
Early Drop off Thursday: 2nd Oct - $8
Early Drop off Friday: 3rd Oct - $8
Late Pick-Ups (til 5pm):
Late Pick Up Monday: 22nd Sep - $8
Late Pick Up Tuesday: 23rd Sep - $8
Late Pick Up Wednesday: 24th Sep - $8
Late Pick Up Thursday: 25th Sep - $8
Late Pick Up Friday: 26th Sep - $8
Late Pick Up Monday: 29th Sep - $8
Late Pick Up Tuesday: 30th Sep - $8
Late Pick Up Wednesday: 1st Oct - $8
Late Pick Up Thursday: 2nd Oct - $8
Late Pick Up Friday: 3rd Oct - $8
Lunch Order Options - 9 options:
Lunch order Monday: 22nd Sep
Lunch order Tuesday: 23rd Sep
Lunch order Wednesday: 24th Sep
Lunch order Thursday: 25th Sep
Lunch order Friday: 26th Sep
Lunch order Monday: 29th Sep
Lunch order Tuesday: 30th Sep
Lunch order Wednesday: 1st Oct
Lunch order Thursday: 2nd Oct
Lunch order Friday: 3rd Oct
please specify your daily lunch order options from the 9 options
I Agree
*
Please bring enough morning tea, lunch, afternoon tea and a refillable drink bottle.
I understand late pick ups between 4:05-5:00pm is extra $8.
I understand late pick ups after 5:00pm is charged $1 per minute.
I understand police or orange tamariki will be contacted if parent/caregiver cannot be reached after 1 hour of scheduled pick up time
Other requirements: early drop off and late pick up and lunch orders can be ordered, please contact us.
I consent for use of any photographs or video recordings that are taken of my child while participating in our programs.
*
Yes
No
I Agree
*
Please contact us 3 working days before your session starts if your child is not coming, otherwise you will charged full amount due to our enrolment policies.
Bricks4Kidz Hamilton will assist you in your WINZ/OT/ACC subsidy application. How much you get depends on the size of your family, your income and how many hours a week your child goes to the childcare provider.
You acknowledge that the responsibility of the booking and the fees incurred are your sole legal responsibility, and payment of all non-subsidised portion of the fees are to be paid before the programme commences.
Outstanding fees resulting from a declined application by WINZ/OT/ACC, are your sole responsibility to pay.
Outstanding amounts, which remain unpaid, will be subject to interest of 2% per month of the remaining account balance once the invoice reaches 30 days overdue.
Unpaid balances may be referred to a debt collection agency, incurring additional costs that will be added to your outstanding balance.
Signature
*
Submit
Should be Empty: