SISTEMA WHANGAREI - New Intake - July Holiday Programme
Event Timing: July 15, 16, 17, 18, 2019
Event Address: 7 Rust Ave, Whangarei - Old Library
Contact us at: Sam - 0274 343 967, Michelle 028 258 20770. sistemawhangareioffice@gmail.com

The information you provide helps us to deliver a programme that best suits your child/whanau. All of this information is kept confidential with the exception of ages and ethnicity as we are required to provide this to our funders for accountability purposes. Without their support we would not be able to deliver this programme free of charge to those that would not be able to attend otherwise. Thank you.

Email address *
Child's Name: First and Last *
Your answer
Name child prefers to be called: *
Your answer
Child's Date of Birth. *
MM
/
DD
/
YYYY
Gender *
Ethnicity most identified with. *
Whanau Contact 1. i.e. parent or main caregiver. *
Please enter Full Name, Address, Phone, Mobile. Separate with commas. Thank you.
Your answer
Contact 2. i.e. parent or main caregiver (in case Contact 1 cannot be reached) *
Please enter Full Name, Address, Phone, Mobile, Email. Separate with commas. Thank you.
Your answer
Who will drop off/pick up child/children? *
Your answer
Is anyone NOT allowed to pick up your child? *
Your answer
Does your child have any special dietary or health requirements? *
Permission for photographs? *
We sometimes take photos of the children and use them in social media or brochures for fundraising etc. Do you give your permission for us to use any photos of your child/children?
A copy of your responses will be emailed to the address you provided.
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