Clone of Sep-Oct 2025 Mt Cook Holiday Programme

Mt Cook January 2026

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

First NameLast Name
Student's Gender:
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?

Other

Please select the programmes you wish to enrol in:

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

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.
Should be Empty: