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

Spaces are limited! Registrations close Friday 13 December 2019. We will let you know on Monday 16 December, if we are able to offer your child(ren) a place

Note: Families who are offered a place on the holiday programme will need to reply back to us by Friday 20th December, to confirm they wish to accept the place(s), and that their child(ren) will be attending.

If you have any questions please email shp@connectingcommunities.org.nz or call/text Ruth 027 641 9229.

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



Email address *
Parent / Legal Guardian 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 child(ren) attend? *
Your answer
Child 1 - First name (Please list children oldest to youngest) *
Your answer
Child 1- Last name *
Your answer
Child 1 - Age *
Your answer
Child 1 - Date of Birth *
Your answer
Child 2 - First name
Your answer
Child 2 - Last name
Your answer
Child 2 - Age
Your answer
Child 2 - Date of Birth
Your answer
Child 3 - First name
Your answer
Child 3 - Last name
Your answer
Child 3 - Age
Your answer
Child 3 - Date of Birth
Your answer
Child 4 - First name
Your answer
Child 4 - Last name
Your answer
Child 4 - Age
Your answer
Child 4 - Date of Birth
Your answer
Does your child(ren) have any medical conditions - asthma, allergies, dietary, other? *
Your answer
Do any of your children require medication whilst they are at the programme?
Your answer
In the event of a medical emergency, do you give permission for your child(ren) to receive treatment *
Do you give permission for your child(ren) to walk home from the programme by themselves? *
Are you happy for photos/videos of your child(ren) 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
In order for CCW to provide a free school holiday programme we depend on partner organisations who assist us with funding and activities. Wairarapa Bush RFU is one of our partners and will be taking registrations and running Rippa Rugby sessions at the school holiday programme. Do you give permission for your child(ren) to be registered with Wairarapa Bush Rugby *
Required
Are you the parent or legal guardian of all the children you are registering? *
Required
A copy of your responses will be emailed to the address you provided.
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