Pukerua Bay After School Care Enrolment Form

*Name of Child

*DOB of Child:

*Gender of Child:

Ethnicity of Child:(Optional)

Any Cultural issues we should be aware of:

*Address Of Child:

Details

*Mothers Name:

*Address:

*Phone Number:

Cell Phone Number:

Fathers Name:

Address:

Phone Number:

Cell Phone Number:

*Emergency Contacts:

(Someone Local staff are able to contact in the event of an emergency) Please List 2

Authorised Caregivers:

Names and Phone Numbers of those authorised to pick up your child

Prohibited Access:

Names and Numbers of anyone who is prohibited access to your child:

Prohibited Access Instructions:

Instructions for staff if this person attempts to collect your child:

Special Needs:

Does your child have any special needs? YES(Please discuss with supervisor) NO

Allergies:

Does your child have any Allergies? Yes (Please fill in separate form)

Medical Problems:

*Child's Doctor and Phone Number

Childs Strengths:

Childs Favourite Recreational Activities:

Days Booked into ASC - Please tick

I have read the Pukerua Bay After School Care Terms and Conditions and Agree to abide by these.

Email Address

*Date: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020