Home School Program

Home School Program

Registration of Interest
Parent Name

First NameLast Name
Parent Email
example@example.com
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child One (1) Name

First NameLast Name
Child One (1) Date Of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please tick the level of support your child requires in the Home School Program
Has this child attended a WRTS Somerville Group Session before?
Child Two (2) Name

First NameLast Name
Child Two (2) Date Of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please tick the level of support your child requires in the program
Has this child attended a WRTS Somerville Group Session before?
Program you want your child to attend:
Please indicate frequency:
MEDICATION My child(ren) will require Medication to be administered by Support Staff during Sessions:
Does your child suffer from any known allergies?
DIETARY REQUIREMENTS & ALLERGIES Some activities have a food element to them. Does your child have any allergies/intolerances? If so, please provide details.
If YES then please describe Allergy, Reaction and treatment (note if your child is Anaphylaxis we will require a Medical Management Plan and the Epi-pen will need to be brought to each session)
Please list interest or things your child likes doing
Please list things that motivate or ways your child might be encouraged to participate
Is your child toilet trained? Details if required.
What is your child's preferred model of communication?
Does your child have physical limitations we should be aware of?
Are they any behaviour or safety concerns that we should be aware of to help your child have a great time?
Upload a copy of your child's Behaviour Support Plan

Cancelof
Do you have any concerns about your child absconding from the Gym?
Has this happened before when your child was with you or in the care of others? If Yes please provide details.
If Yes please provide details:
I have reviewed the program of activities and feel that my child can participate with the following restrictions/adaptions/supports.
BEHAVIOUR CONCERNS: I understand that Management reserves the right to terminate services at any time due to behaviour concerns that may adversely impact the other children and staff. I will be advised verbally and in writing.
HOME SCHOOL ROCKIN' FRIENDS PROGRAM BOOKING CONDITIONS

I understand that by submitting this EOI Form, I am confirming my interest for the Home School Program for the days and programs I have indicated above.

I understand that by submitting this Expression of Interest Form, I will be allocated as many sessions as possible, according to my wishes. I will receive a Booking Confirmation email outlining these sessions.

After my participant receives the services, I will be charged for each session.

I understand that we are NOT Licensed Childcare Provider. Government Fee assistance is NOT available.
MEDIA CONSENT We occasionally post photos from the day on our Instagram and Facebook page to show the daily activities. No names are listed. Are you ok for your child’s image to be posted?
CANCELLATION POLICY: I am aware of and agree to adhere to our Cancellation Policy, as outlined below and agree to adhere to its terms.
Fees for 2025 Program are as follows and are based on the level of support your child requires:

3 Hr Program

1:3 Support $110.37
1:1 Support $257.53
Customer Release of Liability, Indemnity Agreement, and Assumption of Risk for We Rock the Spectrum Facility
In consideration of being permitted by We Rock the Spectrum Kid’s Gym (hereinafter “WRTS”) to participate in its activities and to use its equipmentand facilities, now and in the future, I as parent or legal guardian of the child/ren [named at the bottom of this document] a minor (hereinafter “Minor”),hereby grant the permission necessary to allow Minor to participate in all activities at this WRTS location and agree with all the terms of this Releaseof Liability, Indemnity Agreement, and Assumption of Risk Agreement (hereinafter “Agreement”). I, in my own behalf and on behalf of Minor,further agree to release, indemnify and discharge WRTS, its agents, owners, shareholders, directors, partners, employees, volunteers,manufacturers, participants, lessors, affiliates, its subsidiaries, related and affiliated entities, successors and assigns (hereinafter “Released Parties”),on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

I understand and acknowledge that the activity the Minor is about to voluntarily engage in as a participant bears certain known risks and unanticipated risks which could result in physical, emotional, or mental injury, paralysis, illness or disease, death, or damage to Minor, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activities at WRTS. The risks include, among other things: Use of WRTS equipment entail certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Use of equipment may expose participants to the usual risk of cuts, scrapes, bruises, and rug burns. Other more serious risks exist as well. Participants may fall off equipment, sprain, injure, or break fingers, toes, wrists, feet, legs, back, or neck, and can suffer more serious bodily injuries as well. In any event, if Minor is injured and may require medical assistance, you as parent or legal guardian will assume full liability and responsibility for the expenses.Furthermore, WRTS employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They may give incomplete warnings or instructions, and the equipment being used might become loose, out of adjustment, or malfunction. There is also a risk that WRTS employees may be negligent in, among other things, monitoring and supervising use of its equipment and facilities and in the maintenance and repair of its equipment and facilities.I expressly agree that this Agreement is governed by the State of Victoria, Australia and is intended to be as broad and inclusive as permitted by Victorian and Australian law, and that in the event any portion of this Agreement is determined to be invalid, illegal, or unenforceable, the validity, legality and enforceability of the balance of the Agreement shall not be affected or impaired in any way and shall continue in full legal force and effect. In the event that I file a lawsuit against WRTS, I agree to do so solely in the State of Victoria, Australia and I further agree that the substantive law of the State of Victoria, Australia shall apply in that action without regard to the conflict of the law rules of that state.I further agree to defend, indemnify and hold harmless WRTS from any and all claims or lawsuits for personal injury, property damage or otherwise which are brought by, or on behalf of the Minor, and which are in any way connected with such use or participation by the Minor, including injuries or damages caused by the negligence of Released Parties, except injuries or damages caused by the sole negligence or wilful misconduct of the party seeking indemnity.I agree to grant WRTS and all Related Parties, the irrevocable right and permission to photograph and/or record me or Minor in connection with WRTS to use the photograph and/or recording for all purposes, including advertising and promotional purposes, in any manner in any and all media now or hereafter known, in perpetuity throughout the world, without restriction as to alteration. I waive any right to inspect or approve the use of the photograph and/or recording and acknowledge and agree that the rights granted to this release are without compensation of any kind. All photographs and/or recordings are exclusive to WRTS.By signing this Agreement, I acknowledge that I have had sufficient opportunity to read this entire Agreement, I understand it completely, I understand that it affects my legal rights, and I agree to be bound by its terms. I also agree if anyone is hurt or property damaged during the Minor’s participation in this activity, I may be found by a court of law to have waived my or the Minor participant’s right to maintain a lawsuit against WRTS and the Released Parties on the basis of any claim from which I have released them herein.
By Signing this I agree to all Booking Conditions stated above: (PLEASE ENSURE YOU PRESS SUBMIT WHEN FINISHED)
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: