*Pupils Name

*Teacher

Parent/Caregiver Information

*First Parent/Caregivers Name

*Home Address

*Home Phone

Work Address

Work Phone

Mobile Phone

Email Address

Please supply email address if you would like to receive School Newsletter by email)

Second Parent/Caregivers Name

Home Address

Home Phone

Work Address

Work Phone

Mobil Phone

If your child is cared for by anyone else before or after school, or on particular days of the week, please supply details.

Caregiver Name

Caregiver Address

Caregiver Phone

When is care given?

Emergency Information

*Doctor's Name

Doctor's Phone

If your child becomes ill or is injured at school, state whom we should contact first (ie parent/caregiver) and give alternatives.

*1. Name

*1. Phone

2. Name

2. Phone

3. Name

3. Phone

Civil Defence Emergency
In the event of Pukerua Bay being isolated during school hours please designate a specific local person to whom staff may release your child if you were unavailable.

Name

Phone

Health Information

Health Conditions

Please detail health conditions affecting your child of which we should be aware. Detail any medication or treatment we may need to administer.

*Permission for photos and video images of my children to be used by the school.

Tick your option

*Permission for photos and video images of my children to be uploaded to the school website.

Tick your option