Summer Autumn Winter Spring Please select your prefered programme

Summer Autumn Winter Spring Second choice

Cub details

Medications handed into Supervisor during programme?

Yes
No

Can we apply sunblock to your cub?

Yes
No

Cub's Doctor

Name

Phone Number

Parents/Caregivers details

Name

Day phone

Mobile phone

E-mail

Address

Name

Day phone

Mobile phone

E-mail

Address

Is your cub a confident swimmer?

Emergency contact

Name Phone

Name Phone

Persons other than parents authorised to collect your cub

Name

Name

Permission for trip days

I give consent for my cub(s) to go on trips with the Pride Lands team during this Pride Escape expedition.
I understand the conditions of Pride Lands (see “conditions” on our website: www.pridelands.org.nz).
I agree to abide by these terms.

Is there anything els we should know about?

Can we photograph your cub?

Yes
No

Would you like to recieve a monthly newsletter?

Yes
No

I understand the conditions of Pride Lands and agree to abide by the terms.

I accept the conditions required

Survey (optional)

How did you hear about Pride Lands?

Is there anything we could improve?

This information is private and confidential. Thank you for your support.