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

Days attending:

Parents/Caregivers details

Name

Day phone

Mobile phone

E-mail

Address

Name

Day phone

Mobile phone

E-mail

Address

Company/Organisation Wellington DHB n/a

Employee I.D. No.

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 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.

Is there anything els we should know about?

Can we photograph your cub?

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.