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REGISTRATION FORM
This is the registration form for the Connecting Communities January FREE School Holiday Programme.

Spaces are limited so there is a chance we may not be able to accept all registrations. We will confirm with you by Thursday the 20th of December whether or not you have a place on the programme.

For all the information you need about the holiday programme, please head to www.connectingcommunities.org.nz/school-holiday-programme or contact ruth@connectingcommunities.org.nz

Please note that due to restrictions on numbers priority is given to children who live in the Masterton district.

Email address *
Parent/Caregiver's name *
Your answer
Phone number *
Your answer
Address *
Your answer
Other contact (in case of emergency). Please provide name and phone number: *
Your answer
How many children are you registering? *
Your answer
What school(s) do your children attend? *
Your answer
Child 1 - Full name *
Your answer
Child 1 - Date of Birth *
Your answer
Child 1 - Age *
Your answer
Child 2 - Full name
Your answer
Child 2 - Date of Birth
Your answer
Child 2 - Age
Your answer
Child 3 - Full name
Your answer
Child 3 - Date of Birth
Your answer
Child 3 - Age
Your answer
Child 4 - Full name
Your answer
Child 4 - Date of Birth
Your answer
Child 4 - Age
Your answer
Does your child(ren) have any medical conditions (asthma, allergies, dietary, other) and/or will they require medication at the programme?
Your answer
In the event of a medical emergency, I give permission for my child to receive treatment *
Do you give permission for your child to walk home from the programme by themselves? *
I am happy for photos/videos of my child to be used for marketing or reporting purposes? *
Is there any other information you would like us to know eg, custody/access arrangements, cultural/religious needs, behaviour support?
Your answer
We prioritise families who are working with a social service agency. Please let us know which one you are working with (if applicable)
Your answer
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