Mighty Mites Ski Program Registration (Ages 3 to 5)

One form per family per season

Form not required for Kids Club (ages 6 and 14)

Note: you must accompany your child to Mighty Mites registration DAILY 8.30 – 9.30am at the Big D to reserve their place.

Date of First Enrolment
Child 1 Full Name / DOB / Age
Child 2 Full Name / DOB / Age
Child 3 Full Name / DOB / Age
If your child/ren have any of the following, please identify by their name
Behaviour issues or special needs?
Allergies/Sensitivities/Dietary restrictions?
Medical Conditions?
Currently on Medication?
Do we need to administer any medication? If so, there is an additional form to fill out when signing in.
Was ill in the last 48 hours?
Are they properly immunised as per schedule?
Parent / Guardian 1 Information Parent / Guardian 2 Information
Name / Name
Home Address / Home Address
Suburb / Postal Code / Suburb / Postal Code
Phone (mobile) / Phone (mobile)
Does the Child live with the above Parent / Guardian
Yes No – if no who? / Does the Child live with the above Parent / Guardian
Yes No – if no who?
Email / Email
Language(s) spoken at home other than English / Language(s) spoken at home other than English

Non Parent/ Guardian Emergency Contact

This person may be located off mountain and will be contacted in the case of an accident/illness if you cannot be contacted.

Emergency Contact (Must be someone other than the parents guardians, can be off mountain)
Name
Home Address / Suburb / Postal Code
Phone (mobile) / Relationship to the Child
Other people authorised to collect your child/ren Yes No
Name
Home Address / Suburb / Postal Code
Phone (mobile) / Relationship to the Child
Court orders relating to the child
Are there court orders relating to the children?
No
Yes – please provide the original or certified court order/s for staff to see and attach copies to this document.
Medical and Health Information
Do you consent to the use of the Mt Hotham Medical Centre?
Yes: / Hotham Medical Centre No:
Great Alpine Road
Hotham Heights, VIC 3741
03 5759 3551 / Your registered medical practitioner/medical service
Name
Phone / Practitioner
Declaration
I Consent to the staff of Mount Hotham Skiing Company (MHSC) seeking, or where appropriate, administering, such emergency medical treatment as is necessary and that I will reimburse any necessary expenses incurred by (MHSC).
I understand that this is a learn-to-ski program and that staff will utilise all techniques and avenues available to fully encourage participation. Should my child/ren refuse to participate, become unwell or emotionally distressed. I may be required to collect my child/ren or make arrangements to collect my child/ren as soon as possible.
I understand that I need to remain contactable by (such as keeping my mobile phone powered on) while my children are in the care of (MHSC).
I understand that my contact details may be used by (MHSC) to communicate with me about any relevant changes to our ski programs
I agree to allow my child/ren to be photographed or videoed participating in the (MHSC) activities; Photos and videos may be used by (MHSC) or Nestle for promotional or advertising purposes.
I authorise (MHSC) staff, in the event the children’s own ski equipment fails, to rent other ski equipment for the child; I agree to reimburse (MHSC) for costs associated with such rental equipment.
I understand that by filling in this form, and/or purchasing a (MHSC) ticket, I have not reserved, booked, or otherwise guaranteed a place in the Mighty Mites program and that I must be present at the Big D DAILY between 8.30am and 9.30am to register my child/ren to take part in the Mighty Mites Program.
I declare that the information above is correct and will immediately inform (MHSC) in the event of any change to this information.
Parent/Guardian Name and Signature / Date

Once completed this form can be emailed to or brought in person on the day of your lessons. More information can be found at Hotham.com.au/kids.

MM-Reg-01(RevJune2016)