Boredom Busters 9-12 Years - April 2026 Registration Form

Murchison Sport, Recreation & Cultural Centre

82 Waller Street

Murchison 7007

murchison.centre@gmail.com

03 523 9360

021 426 981

CHILD(REN) DETAILS - Please fill out your childs details below.

Child # 1

First NameLast Name

Birth Date

DayMonthYear

Gender

Child #2 (Optional)

First NameLast Name

Birth Date

DayMonthYear

Gender

Child #3 (Optional)

First NameLast Name

Birth Date

DayMonthYear

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PRIMARY CAREGIVER DETAILS - Please fill out the Childs primary caregiver details below, this is the person we would communicate with about Boredom Busters.

Caregiver Name

First NameLast Name

Caregiver Phone

Area CodePhone Number

Caregiver Email

example@example.com

ENROLMENT DETAILS - Please select which days you would like to enrol your child/children. Our Boredom Busters 9-12 year old programme currently runs from 1pm until 3pm, on the following days and at the cost of $10 per child, per day. Please note there are only 12 spaces available per session.

PHOTOGRAPHS: I consent to my child being photographed and these photographs to be used in any media coverage in regards to the promotion of the programme

EMERGENCY CONTACTS & PEOPLE AUTHORISED TO COLLECT YOUR CHILD(REN)
Please list people who are to be contacted in an Emergency, if we are unable to reach you. These contacts will also be authorised to collect your child(ren).

NameContact Number

MEDICAL REQUIREMENTS / OTHER INFORMATION
Detail below any Medical or Other requirements for your Child(ren).

MEDICAL REQUIREMENTS: Are there any health needs we need to be aware of for your child(ren) – e.g. asthma, medical conditions, allergies, disabilities? (If this form is for more than one child, please clearly indicate for whom the health needs apply). Also, If your Child(ren) are required to have medication with them please indicate this below and if any assistance is required in taking the medication.

If the need arises, do you give MRSCC staff permission to provide the following pain relief:

OTHER INFORMATION: Is there anything else we should know about in order to take good care of your child(ren) – e.g. Custody arrangements, behaviour management strategies, special interests, cultural considerations or any other questions you may have for our team.

ENROLMENT DETAILS -

Boredom Busters these school holidays will be on Wednesday 8th & Thursday 9th July and Tuesday 14th & Wednesday 15th July 2026

Sarah Peacock our Activity Coordinator will be running these days.

Sessions start from 1pm until 3pm.

Registration requires payment up front to confirm your childs spot.

No refunds will be provided.

Registration Costs are $10.00 per child per day

This can be paid to MSRCC 03-1354-0144276-02 Ref: Childs name

If for any reason your child will be absent from the program on any given day registered, please notify the Centre.

PRIVACY ACT
The information supplied on this form will be held securely in the MSRCC Office and used only for the safe and effective operation of our Boredom Busters programme. Parents/Guardians are welcome to view and/or update this information at any time by contacting the MSRCC Management Team.

PARENT/GUARDIAN DECLARATION
By completing and signing this form, MSRCC has the Parent/Guardians permission to arrange any urgent medical treatment for the child(ren) listed above. This will be at the Parent/Guardians cost. Should the need arise, minor first aid will be
administered by one of the trained programme staff on site.

I confirm have read and understood the above. What I have written is true and accurate and I have not withheld any information, especially about my child(ren)'s health.

Signature of Primary Caregiver

Date