Social Thinking Holiday Program
Registration of Interest
Name (participant)
*
First Name
Last Name
Date of birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Age
*
Name of parent/carer
*
First Name
Last Name
Email
*
Phone Number
*
Format: 0000-000-000.
Preferred Method of Contact
*
Phone
SMS
Email
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What is your date preference for the program?
Tuesday 12th - Thursday 14th January
Tuesday 19th - Thursday 21st January
Please note that while we will do our best to accommodate your preference, they are not guaranteed. Final dates and times will be confirmed closer to the start of the program
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Signature
*
Date
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Name of Signatory
*
Relationship to Participant
*
Submit
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