Katharine Susannah Prichard Writers’ Centre
April 2015 School Holiday Write-A-Rama
(Sponsored by the Dept for Culture and the Arts)
Enrolment Form
I, ………………………………………………….. (Parent/Legal Guardian)
Address: ………………………………………………….. …………………………….
Home Tel: …………………………………………………..
Work Tel: …………………………………………………..
Mobile: ………………………………………………….. (Parent/Legal Guardian)
………………………………………………….. (Participant)
Email:………………………………………………….. (Parent/Legal Guardian)
………………………………………………….. (Participant)
Relationship:…………………………………………………..
Wish to enrol ………………………………………………… Age ……..
at the KSP Writers’ Centre, 11 Old York Road, Greenmount 6056
Monday April 13 from 9:30 AM to 4 PM and Thursday April 16 from 9:30 AM to 4 PMand the Perth Cultural Centre, Roe Street Northbridge
Wednesday April 15 from 10:00 AM to 3:30 PM (please see details below)
Cost:$160 for non-members, plus $25 excursion fee
$130 for KSP members, plus $25 excursion fee
KSP Membership Fee: Family $ 75 Concession/Youth $ 55
Total Amount $ ………………………
Payment to be made in advance by Visa/Mastercard (by phone, or see below), money order or cheque, or by direct deposit to: KSP Foundation Inc. BSB: 633-000 Acct No: 147352983 (Use reference SURNAME WAR). Then email your booking and payment details to for confirmation. Please make cheques out to the Katharine Susannah Prichard Foundation and cross them ‘Not negotiable’.
I authorise KSP Foundation Inc. to process payment of $______being for Write-a-Rama April 2015.
Credit card (Mastercard or VISA). Card no: ______
Expiry:______3 Digit Code (CVC): ______Signature: ______
Any special medical conditions or medication or any special dietary requirements: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Anything else you need to inform us about: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………
I am available to assist from 10:00 AM to 3:30 PM Wednesday April 15th at the excursion to The Art Gallery of WA, Miss Maud’s and The City of Perth YES NO (Please circle - if yes, please provide name and mobile phone number)
……………………………………………………………………………………………………………..
I am available to help with carpool transport between KSP Writers Centre and Perth Cultural Centre on Wednesday, April 15th YES NO (Please circle - if yes how many children you can transport in addition to your own child/children?)
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Please sign here to indicate your consent for your child to take part in the Write-A-Rama excursion, in accordance with the following conditions:
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My child will need private carpool transport on Wednesday April 15th from KSP Writers Centre to Perth Cultural Centre, Roe St Northbridge. YES NO (please circle)
My child will meet the KSP group in front of the Art Gallery of WA at the Perth Cultural Centre, Roe St Northbridge, at 10:00 AM on Wednesday April 15th and I will pick him/her up from the same location at 3:30 PM. YES NO (please circle)
I give my child permission to take public transport to and from the Perth Cultural Centre, Roe St Northbridge on Wednesday April 15th. YES NO (please circle)
Participants will need to bring:
Monday at KSP: pens and notebook or paper, morning tea and lunch and a water bottle, laptop if wanted/available for your child
Wednesday at the Perth Cultural Centre: pens and pencil and notebook or paper, water bottle, hat and sunscreen if needed
Thursday at KSP: plate of afternoon tea to share, pens and notebook or paper, laptop if available, copy of work from previous days (a digital copy on a pen drive would be excellent), morning tea and lunch, water bottle
Cancellation Policy:
Once payment has been received, cancellations incur the following fees:
More than 1 week prior to the Write-A-Rama: no cancellation fee
More than 4 days prior to the Write-A-Rama: $25 per child
Less than 4 days prior to the Write-A-Rama: full payment – there will be no refund
Enrol soon to ensure a place as numbers are limited to 20 participants
PHOTOGRAPHY RELEASE AND CONSENT FORM
Consent of use of photographs and media images
I agree that KSP may publish photographs or media images taken of me at KSP related events to be used for promotional purposes such as media articles, KSP newsletters, webpage or other publication.
Name:------
Address:------
Age: (if relevant)------
Date:------
If under 18 years of age, the parent or guardian of the person photographed or in the images has read this release and agrees with it on their behalf
Name parent / guardian------
Address:------
Signature:------
Date:------