Registration Form
Registration for DBX 2017
This Program is run at Knox Church Waitara on Tuesdays Afternoons from 3.15-5.15pm for Girls and 6-7.30pm for boys. It costs $2 a day per child. Afternoon tea and supper are included.
Child's name *
Your answer
Child's date of birth *
MM
/
DD
/
YYYY
Child's Gender *
School Attending *
Your answer
Child's name
First and Last
Your answer
Child's date of birth
MM
/
DD
/
YYYY
Child's Gender
School Attending
Your answer
Child's name
First and Last
Your answer
Child's date of birth
MM
/
DD
/
YYYY
Child's Gender
School Attending
Your answer
Parent Information
Please fill in the form and indicate if a part is specific to only one of your children.
Parents/Guardians Name: *
Your answer
Address
Your answer
Email Address *
Your answer
Home Phone
Your answer
Mobile Phone
Your answer
Alternative Contacts
Please include two other alternative contact
Contact 1 Name *
Your answer
Contact 1 Phone Number *
Your answer
Contact 1 Mobile Number *
Your answer
Contact 2 Name *
Your answer
Contact 2 Phone Number *
Your answer
Contact 2 Mobile Number *
Your answer
Medical/Special Requirements
Please indicate the child/children that requirements are for.
Medical requirements *
Please include any allergies, medical needs or special care that the leaders should be aware of. If you do not have any please respond N/A.
Your answer
Child's Doctor Information *
Please include doctors name, practice, and phone number
Your answer
Do you give permission for your child's photo to be displayed in the church/ newspaper/ DBX Waitara Facebook Page *
Required
Does your child have permission to walk to and from the DBX on tuesdays. *
Required
Is there anyone else who has permission to pick up your child/children from the program? *
Please include name and phone number.
Your answer
Do you give permission for your child to be transported by vehicle to different venues? *
All drivers will have a fully regestered and warrented car, as well as a full licence
Declaration
Parent Declaration *
I/we agree and acknowledge: I have read and understand the enrolment information. The supervisor has my permission to arrange any necessary urgent medical treatment at my cost. I will notify the supervisor of any changes to enrolment information in a timely fashion.
Required
Name & Date *
Your answer
Submit
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