Pipsqueaks Enrolment Form

Afternoons enrolling for:

Emergency Contact Details

Who should Pipsqueaks contact in case of an emergency, if the Primary Contacts are unreachable?
Emergency Contact*

First NameLast Name
Daytime phone:
Format: (00) 000-0000.
Mobile Phone*
Relationship to Child*

Medical Conditions
YesNo
Please describe any medical conditions/allergies
YesNo
Medication Type 1
Dosage 1
Medication Type 2
Dosage 2
SERIOUS INJURY

In the event of a more serious injury we would contact a Parent/Caregiver.

LIFE THREATENING INJURY

In the event of a life threatening injury an ambulance will be called.
By signing below, I give my authority to the Supervisor/Assistant supervisor of Pipsqueaks After School Care to administer medication provided by me as detailed in this form.
Signature of Parent/Guardian

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Date Signed

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Should be Empty:

Enrolment Form