All Fields Must Be Completed for a Successful Booking

December Registration and Payment Form

All fields must be completed for a successful booking.

Enrolments Close Friday December 14th 2012

1.  Child 1 Details

Child’s Full Name: ______Age: _____ Sex (circle): Male Female

Child’s School: ______Is this their first ECU Kids Holiday Program? YES NO

Child 2 Details

Child’s Full Name: ______Age: _____ Sex (circle): Male Female

Child’s School: ______Is this their first ECU Kids Holiday Program? YES NO

2.  Parent / Guardian Details

Parent Full Name:______Address: ______Suburb: ______Postcode: ______Phone: (home)______(mobile)______Email:______@______

3.  Emergency Contact Details (Secondary)

Full Name:______(mobile)______(Relationship to Child)______

4.  Childs Attendance (mark with an X) Joondalup Mount Lawley

DAY/DATE / FULL DAY
8 - 5:30PM / HALF DAY
8-12PM 12-5PM
CHILD / 1 2 / 1 2 1 2
MONDAY 17th December / No Kids Holiday Program On Today
TUESDAY
18th December / No Kids Holiday Program On Today
WEDNESDAY
19th December
THURSDAY
20th December
FRIDAY
21st December

5.  Prices Number of days TOTAL $

FULL DAY / $40 / Child
HALF DAY / $25 / Child

6.  Medical Condition

Medical Conditions :______( please specify)

Should your child suffer from any medical condition, please complete a medical form (download from website), & discuss with Kids Holiday Program supervisor each day you drop your child off.

Custody information

Is there any custodial information or any Family Court orders affecting custody of, or access to the child?

No Yes If yes, please give details and provide a copy of the court order:______

7.  Terms and Conditions

A.  Edith Cowan University (ECU) and its employees, agents or contractors shall not be liable in negligence for any loss, damage or harm suffered by participants in the ECU Kids Holiday Program (including, without limitation, theft or damage to personal property, personal injury or death).

B.  You warrant that ECU has informed you of the activities that make up the ECU Kids Holiday Program and that they are suitable for your child to participate in.

C.  In the event of a medical emergency involving your child, ECU will seek all necessary medical assistance. You will indemnify ECU against any costs ECU might incur in seeking such medical assistance.

D.  ECU Kids Holiday Program Staff have the right to confiscate any electronic devices which can be collected by the parents at the end of the day.

E.  ECU reserves the right to remove any child from the ECU Kids Holiday Program where the child’s behaviour is, in the opinion of ECU, seriously disruptive or inappropriate.

I have completed a medical form (if applicable) in point 6.

I give permission for my child to watch G or PG rated movies.

I give permission for my child to be photographed

I give ECU Sports permission to supply and assist with the application of sunscreen for my child.

Parent / Guardian Signature: ______Date: ____/____/20_____

8.  Payment Details - Please fax: Joondalup - 6304 5333 / Mt Lawley - 9370 6722 or deliver to the ECU Sports Centre

Amount Due: $______

Payment Type: Cash EFTPOS Cheque Voucher

Salary Package (Download form from www.ecu.edu.au/sport/kids) Payroll form attached

Visa/Mastercard *Complete item 9 at the end of this form for Credit Card payment to be processed

Office Use Only

Receipt Number: ______Receipt Date: ____/____/______Staff Rep: ______

Entered In: Database ____/____/______

9.  Credit Card Payment – This section will be destroyed once processed

Credit Card Number: CVV Expiry Date

- / - / - /

Name on card: ______Signature: ______