School Holiday Programme Registration Form
Location
Please Select
Wellington
Christchurch
Parent / Carer Name
*
Parent / Carer Email Address
example@example.com
Parent / Carer Contact Phone Number
*
Parent / Carer Address
*
Have you registered before?
*
Please Select
Yes
No
Name of Child
*
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Childs Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name
*
Emergency Contact Phone Number
*
Emergency Contact Relationship to Child
*
What special interests does the child have?
Has your child had a formal diagnosis? If Yes, please provide more info.
Describe your child's communication capability, i.e. non verbal, verbal with limited vocabulary, good communication
*
Any known triggers to be aware of?
Toileting capability
*
No assistance needed
Assistance needed
Other
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Does your child have any allergies? Please list all allergies and type of reaction
Does your child need to take any medication during the day? If yes, provide additional details.
Are you comfortable with your child eating in a shared food situation?
*
Yes
No
Other
Are you comfortable with your child's picture being shared on social media (with face covered)?
*
Yes
No
Other
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Session times you would like the child to attend - week 1 (click all sessions that you would like the child to attend)
Monday 9am - 12pm
Monday 1pm - 4pm
Tuesday 9am - 12pm
Tuesday 1pm - 4pm
Wednesday 9am - 12pm
Wednesday 1pm - 4pm
Thursday 9am - 12pm
Thursday 1pm - 4pm
Friday 9am - 12pm
Friday 1pm - 4pm
Session times you would like the child to attend - week 2 (click all sessions that you would like the child to attend)
Monday 9am - 12pm
Monday 1pm - 4pm
Tuesday 9am - 12pm
Tuesday 1pm - 4pm
Wednesday 9am - 12pm
Wednesday 1pm - 4pm
Thursday 9am - 12pm
Thursday 1pm - 4pm
Friday 9am - 12pm
Friday 1pm - 4pm
Payment Options (note your place will be confirmed once payment is received)
*
By Invoicing (including IF)
Carer Support (please contact emma@positivepathways.nz and send your Client ID)
Submit
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