2 Dodds Street, Port Macquarie NSW 2444
Phone: 6583 8044
Email: enquiry.portmacquarie@hns.org.au
HNS Kids Activity Enrolment Form
Please note, because people visiting our Centres include children, all our paid staff, volunteers, facilitators and student placements have valid and verified up to date NSW Working with Children Checks. Please complete the intake questions below.
1. Personal Details:
Parent or Care Givers Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Postcode
Gender:
*
Male
Female
Other
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 0000-000-000.
Do you identify as:
*
Aboriginal
Torres Strait Islander
Are you from a Culturally and/or Linguistically Diverse Background
None of the above
Language(s) spoken:
*
English
Other
Other language if selected
Number of Adults in Your Household
*
Number of Children In Your Care
*
1. Childs Full Name
*
First Name
Last Name
2. Childs Full Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender:
*
Male
Female
Other
Gender:
*
Male
Female
Other
3. Childs Full Name
First Name
Last Name
4. Childs Full Name
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender:
*
Male
Female
Other
Gender:
*
Male
Female
Other
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2.Permission Slip:
I give permission for my child/children to:
*
Participate in our HNS Tiny Tots Playgroup
Attend and participate in our Kid's Club activities
Attend and participate in the Excursion activities listed below
Be transported by bus to the designated Excursion listed below
Have their photo taken to be used in PMNC marketing materials
Be provided with First Aid or medical treatment should an accident occur or if I or my Emergency Contact cannot be reached.
I give permission for all information provided in this form to be entered into the Neighbourhood Centre's record system, the DSS DEX data base and kept for reporting purposes.
Childs Name
*
Date and Activity Enrolled In
*
Childs Name
Date and Activity Enrolled In
Childs Name
Date and Activity Enrolled In
Childs Name
Date and Activity Enrolled In
Does your child have?
*
Allergies / Medical Condition
Special Dietary Needs
Special Support Needs
None of the Above
Other
If yes, please provide each child's first name and detailed information regarding allergy and treatment plan, dietary needs or special support needs so that our facilitators may accommodate your child's needs.
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3. Stay Up To Date:
Enter your email to Subscribe to our Newsletter to stay up to date with our Programs.
*
example@example.com
Name
*
First Name
Last Name
Parent or Care Givers Signature
*
Form completion date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Save
Submit
Should be Empty: