Pride Lands - Fun Holiday Adventures Enrolment

Fun Holiday Adventures Enrolment

I am an existing / returning parent enrolling the same cub(s)

I am a new parent / existing parent enrolling new cub(s).

Parents name:

Email address:

How many cubs would you like to enrol?

1 2 3 4 5

School choice

Cub(s) details

Child 1

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Name Condition:

Medical Instrument (If applicable, e.g. inhaler):

Mild to Moderate Allergic Reaction:
(Watch for any one of the following signs):

Severe Allergic Reaction:
(Watch for any one of the following signs):

Plan prepared by:

Name(s):

Designation:

Date:

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 2

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 3

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 4

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 5

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Shuttle Service

Do you require a shuttle service?

Yes
No

Pick-Up from?
Drop-Off to?
Both
From? To?
and From? To?

Time Preference (We aim to get as close as possible to your preferred time)

Pick-up time:
Between: To
Drop-off time:
Between: To

Holiday season

Summer Autumn Winter Spring Extra school holidays

Days attending:

Summer

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2
All week 3
All week 4

Autumn

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2

Winter

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2

Spring

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2

Extra school holidays / Teacher only days

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week

Please use my existing Before School Care / After School Care / Fun Holiday Adventures / Pride Escape Enrolement details you have for my cub(s)

Is there anything else we should know about?

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

I accept the conditions required.

This information is private and confidential.

Thank you for your support.

How many cubs would you like to enrol?

1 2 3 4 5

School choice

Cub(s) details

Child 1

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 2

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 3

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 4

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Child 5

Name

Male
Female

Date of birth

Age

Any medical conditions?
Yes
No

Please specify

ALLERGIC REACTION PLAN
Does your cub(s) have an allergy?
Yes
No

Will you cub require a one on one support?
Yes
No

Please specify the reasons why:

Does your cub take any medication(s)?

Yes
No

Medications handed into Supervisor during programme

Yes
No

Can we apply sunblock to your cub?

Yes
No

Is there any cultural requirements we need to be aware of when it comes to your cub(s)?

Yes
No

please specify

Cub(s) Doctor

Name

Phone Number

Home Work Assistance

Yes
No

Shuttle Service

Do you require a shuttle service?

Yes
No

Pick-Up from?
Drop-Off to?
Both
From? To?
and From? To?

Time Preference (We aim to get as close as possible to your preferred time)

Pick-up time:
Between: To
Drop-off time:
Between: To

Wild Card Discounts (15% Off All Services)

Yes
Already have one
No

Wild Gift Card

Do you have a Wild Gift Card?
Yes
No

Please enter your reference number:

Holiday season

Summer Autumn Winter Spring Extra school holidays

Days attending:

Summer

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2
All week 3
All week 4

Autumn

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2

Winter

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2

Spring

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week 1
All week 2

Extra school holidays / Teacher only days

Please select week or days attending
All week	Monday	Tuesday	Wednesday	Thursday	Friday
All week

How many parents do your cub(s) have?

1 2 3 4

Parents/Caregivers details

Parent 1

Name

Day phone

Mobile phone

E-mail

Address

Parent 2

Name

Day phone

Mobile phone

E-mail

Address

Parent 3

Name

Day phone

Mobile phone

E-mail

Address

Parent 4

Name

Day phone

Mobile phone

E-mail

Address

Company/Organisation

Employee I.D. No.

How many emergency contacts does your cub(s) have? (requires at least two emergency contacts)

2 3 4 5

Emergency contact

Name Phone

How many people are authorised to collect your cub(s)?

1 2 3 4 5

Persons other than parents authorised to collect your cub(s)

Name Phone

Are you a refugee?

Yes (Scan and E-mail refugee status)
No

Are you eligible for a WINZ subsidy?

Yes
No
Don't Know

Permission for trip days

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

Yes
No

Is there anything else we should know about?

Can we photograph your cub(s)?

Yes
No

Would you like to receive regular E-mail updates?

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.

Fun Holiday Adventures Enrolment

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