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Youth & Family Programs Pesach 4D Experience

Daycamp Holiday Program-General enrolment

Pesach 4D experience Holiday Program
CHILD 1 INFORMATION
Child 1 Full Name*
First NameLast Name
NIcknamename they like to be called
Birth Date*
DayMonthYear
School
Grade 2019*
What day is my child attending? Select 1*
Sunday April 14Tuesday april 16
MEDICAL INFO & SPECIAL NEEDS
GP Name*
GP Number*
Any Allergies?*
please write NA if none
Medical Conditions (asthma or others)?*
please write N/A if none
Child Special Needs/Difficulty (Disability)
Special Comments
CHILD 2 INFORMATION
Child 2 Full Name
First NameLast Name
Child 2 Nicknamename they like to be called
Birth Date
MonthDayYear
School
Grade 2019
What day is my child attending
Tuesday April 16
Child 2 MEDICAL INFO & SPECIAL NEEDS
GP Name
GP Number
Any Allergies?
please write NA if none
Medical Conditions (asthma or others)?
please write N/A if none
Child Special Needs/Difficulty (Disability)
Special Comments
FAMILY INFORMATION

Address

Street Address
Street Address Line 2
City	State
Post Code	Country

Family E-mail
Parent 1*
First NameLast Name
Contact Number*
Phone Number
Parent 2
First NameLast Name
Contact Number
Phone Number
Home Phone Number
Area CodePhone Number
Emergency Contact other than Parents*
First NameLast Name
Emergency Contact Number*
Area CodePhone Number
Authorised Person1 to collect the child
First NameLast Name
Authorised Person2 to collect the child
First NameLast Name
Is the natural mother of the child Jewish*
YesNo
Are there any conversions in the family?*
YesNo
If yes, please specifiy whom and through which organisation
AUTHORISATIONS
Medical Authorisation*
I hereby authorise a L'Chaim Chabad or Moorabbin HC staff and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical*
I hereby authorise L"Chaim Chabad or Moorabbin HC staff and/or volunteers to photograph my child and use the photographs for L'Chaim Chabad or Moorabbin HC for the following purposes:
yes, Educational purposesyes, promotional materialyes, social media
I hereby authorise L'Chaim Chabad or Moorabbin HC staff and/or volunteers to take my child on walks outside the facility
*
yesno
PAYMENT INFORMATION
Cost is $10/per child due to a generous donor.

Payment

Credit Card Direct Debit

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