Kids Domain STOKES VALLEY - Before and After School Care Enrolment

KIDS DOMAIN STOKES VALLEY

BEFORE & AFTER SCHOOL CARE ENROLMENT

Please select or write N/A if something does not apply to you (1 child per form)

TRANSPORT to/from school is dependant on availabilty - please check with us if you need this service before booking

Centre to be Enrolled *

Child *

First Name Last Name

sex of child *

female male

Date of Birth *

School Attending *

Classroom Number/Teacher's Name *

Transportation to or From School is required *

Yes No

Transportation has been confirmed by Management in writing *

Yes No (Please do not carry on with this form until a confirmation has been received. Email kidsdomain@slingshot.co.nz to find out if there is availability first)

Mother/Caregiver *

First Name Last Name

Home Address *

Home Phone *

Mobile Phone *

Work Phone *

Please choose: *

Employer *

Work Email

example@example.com

Name of institution where you are studying *

Father/Caregiver *

First Name Last Name

Home Address *

Home Phone *

Mobile Phone *

Work Phone *

Please choose: *

Employer *

Work Email

example@example.com

Name of institution where you are studying *

Email address for billing *

PEOPLE WHO ARE AUTHORISED TO COLLECT MY CHILD (Your child will NOT be allowed to leave with any person, even a friend or a relative if they are not listed below. Please fill in as many people as required. This includes the names of people who are delegated by you to collect your child in a civil emergency such as flood or earthquake *

If we are unable to contact you (the parent/caregiver) for any reason, who are the best people to contact?

1st Emergency Contact Full Name *

Relationship to Child *

Best Contact Phone Number(s) *

2nd Emergency Contact Full Name *

Relationship to Child *

Best Contact Phone Number(s) *

DOES YOUR CHILD HAVE....

Allergies (e.g food, insects, medicines) *

YES NO

Special Needs/disability (e.g behavioural, ADHD, ADD, Autism, Aspergers etc) *

YES NO

Any medical conditions (e.g asthma, diabetes) *

YES NO

Custody arrangements (e.g Oranga Tamariki, family courts etc) *

YES NO

Religious, social, cultural or ethnic requirements *

YES NO

Special instructions (permission to walk to parents work/home, or anything else you would like to let our supervisors know *

YES NO

PLEASE SPECIFY DETAILS HERE *

Child's Doctor or Medical Centre *

BOOKINGS

please tick the appropriate boxes

TYPE OF PLACEMENT REQUIRED. Permanent placements are reserved for your child on the days you book below. Casual placements are non reserved with no guarantees there will be a placement on the day *

Permanent Booking Casual Booking

IS CARE REQUIRED ON MONDAY. *

YES NO

MONDAY SESSION REQUIRED. *