Magnolia Girls' Club
Fernhall Study Centre
A: 129 Gillies Avenue, Epsom, Auckland 1023
P: +64 9 623 9003
E: admin@fernhall.org
Email address *
Daughter's Name *
Your answer
Surname *
Your answer
Date Birth *
MM
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DD
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YYYY
School *
Your answer
School year *
Parent/Guardian Names *
Your answer
Address *
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Phone Number (Home)
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Mobile Number *
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Does your daughter suffer from any allergies/medical condition? *
If yes, please specify allergy/ details of condition and treatment
Your answer
I was referred to the club by: *
Your answer
I, (write your name below) give permission to my daughter to participate in the activities conducted by Fernhall. It is understood that every precaution will be taken for the safety and well-being of my child, but in the event of accident or sickness, Fernhall, its staff and its volunteers, are hereby released from anyliability. In the event that the club volunteers is unable to contact me or it is otherwise impracticable to contact me, I provide my consent for; The administering of any first aid to my child as is deemed necessary by the staff and volunteers of Fernhall study centre or a recognised first aid provider; Any transportation, including ambulance transportation, as is deemed necessary by the staff and volunteers of Fernhall; And any further medical or surgical intervention deemed necessary by the medical practitioner into whose care my child is delivered; And that all cost involved, including transportation cost, will be paid by the parent/guardian of the child who has received such medical treatment as outlined above. *
Your answer
Media consent. I agree/do not agree* to allow Fernhall to use my daughter’s images, photographs, videos for Fernhall's promotions and advertisements. *
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