Enrolment Form

To enrol in our After School programme please complete the online form below or download, complete and return the following PDF form:

After School Enrolment Form

Child's Name

Child’s DOB

Male/Female

	Male
	Female

Parent/Guardian Name

Address

Phone (daytime)

Phone (evening)

Phone (mobile)

Email*

School attended

Days Required

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday

Emergency Contact 1

Please include name, relationship to child, and home, work and mobile phone numbers for each person

Emergency Contact 2

Please include name, relationship to child, and home, work and mobile phone numbers for each person

Other adults authorised to pick up children

Please include name, relationship to child, and home, work and mobile phone numbers for each person

Family Doctor

Family Doctor Phone

Health Record

Please specify allergies and ailments (eg asthma, bee stings, food, penicillin, epilepsy), medical conditions, and assistance required

Medication

To be provided by parent/guardian. Please include dosage amount.

Is there any other information the Programme should be aware of?

Declaration*

I accept the terms and conditions set out below.

1. I acknowledge that ASB Stadium Staff will run the After-School Programme.2. I agree to these Staff seeking medical aid for my child/ren enrolled on this Programme, if such aid is considered necessary by these staff. I shall meet any cost incurred in obtaining such aid. 3. I agree to all Staff administering the medication as prescribed in the enrolment form above, and will train staff if necessary. 4. I agree not to enrol any child/ren on the Programme who is sick, and understand that a sick child will not be able to attend. 5. I agree to inform the Staff of any known medical condition which is infectious or contagious, to assure that appropriate precautionary action can be taken. 6. I agree to provide adequate health protection equipment/aids for my child, eg. sunblock, insect repellent, etc. 7. I understand that the Programme Staff will exercise all reasonable care in respect of my child/ren during the Programme for which they are enrolled but not withstanding I agree that the ASB Stadium will not be in any manner liable for any injury or accident suffered by my child/ren or for any damage to or loss of their possessions incurred during such Programme. 8. I understand that extra charges may be incurred if my child/ren is not collected as agreed. 9. In the case of an emergency, parents will be contacted immediately and the child taken to the nearest Accident & Emergency Clinic for treatment. Information on this form is for the purposes of contacting the Parent/Guardian/Doctor in case of emergency, and for the administration of the Programme.

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