Enrolment Closes Friday 4 July 2014 1. Child 1 Details

Enrolment Closes Friday 4th July 2014
1. Child 1 Details
Child’s Full Name: _________________________________________
Child’s School: __________________________________
DOB: _____
Sex:
Male
Is this their first ECU Kids Holiday Program?
Female
YES
NO
Child 2 Details
Child’s Full Name: _________________________________________
Child’s School: __________________________________
DOB: _____
Sex:
Male
Is this their first ECU Kids Holiday Program?
Female
YES
NO
2. Parent / Guardian Details
Parent Full Name:______________________________________
Address: ________________________________________
Suburb: ____________________Postcode: ________ Phone: (home)_________________(mobile)_________________________
Email:_____________________________________________@___________________________________
3. Emergency Contact Details (Different from above)
Full Name:____________________________ (mobile)_______________________(Relationship to Child/ren)__________________
4. Childs Attendance (mark with a tick)
DAY/DATE
CHILD
HALF DAY
FULL DAY
8 - 5:30PM
8-12PM
1
1
2
2
12-5PM
1
2
MONDAY
14th July
TUESDAY
8th July
TUESDAY
15th July
WEDNESDAY
9th July
WEDNESDAY
16th July
THURSDAY
10th July
THURSDAY
17th July
FRIDAY
11th July
FRIDAY
18th July
Campus:
1
CHILD
MONDAY
7th July
 Joondalup
HALF DAY
FULL DAY
8 - 5:30PM
DAY/DATE
2
8-12PM
1
Number of days
$42 per child
HALF DAY
$26 per child
1 week
(5 CONSECUTIVE
FULL DAYS)
$186 per
child
$175 / 2+
children
1
2
 Mt Lawley
5. Prices
FULL DAY
2
12-5PM
TOTAL $
Bookings and
payments on day of
service will incur a $5
surcharge.
GRAND TOTAL
KHP Registration Form
All printed copies are uncontrolled
Page 1 of 2
As at June 2014
Issue 5
6. Medical and/or Custody Condition
Does your child/ren suffer from any medical condition?
 Yes*  No
Is there any custodial information or any Family Court orders affecting custody of, or access to the child/ren?  Yes*  No
* If you answer yes, please complete and forward to ECU the Medical & Custody along with this form. Form located
at www.ecu.edu.au/sport/khp . You are required to discuss your child’s medical condition(s) with the ECU Kids Holiday Program
(Program) supervisor each day when you drop your child off.
7. Terms and Conditions
Edith Cowan University (ECU) and its employees, agents or contractors shall not be liable for any loss, damage, injury or harm
suffered by you, your child or children, in connection with the Program howsoever caused.
B. You acknowledge that you are aware of the various activities (including sporting activities) that make up the Program. You warrant
that each child you are enrolling in the Program is mentally and physically capable to participate in Program’s activities.
C. ECU requires that children participating in the Program be clothed appropriately for physical activity with enclosed footwear. You
agree to ensure that your child or children will meet these requirements while participating in the Program.
D. In the event of a medical emergency involving your child or children, you consent to ECU seeking all necessary medical assistance
in response to that emergency. You agree to indemnify ECU against any costs ECU might incur in seeking such medical
assistance.
E. You agree that Program staff have the right to confiscate any electronic devices from your children during the Program.
Confiscated devices can be collected by the parents/guardians at the end of the day.
F. You give permission for your child or children to watch G or PG rated movies during the Program.
G. You give permission for Program staff to supply sunscreen to your child or children and assist with them with sunscreen application
if necessary.
H. ECU reserves the right to remove any child from the Program where their behaviour is, in the opinion of ECU, seriously disruptive
or inappropriate.
I. You confirm you have:
A.
•
if applicable, completed and attached a Medical & Custody Form (point 6);
•
if applicable, discussed any medication requirements your child is likely to have during the Program with the Program
Coordinator.
Parent / Guardian Signature: _________________________________ Date: ____/____/2014
Type name if submitting electronic copy
8. Payment Details - Please fax: Joondalup - 6304 5333 / Mt Lawley - 9370 6722 or deliver to the ECU Sports Centre
NOTE: Please ensure when you book and pay that the dates booked are true and correct.
We DO NOT offer refunds on our program. Where possible, transfers will be accommodated.
Your child’s place in the program will only be secured once payment has been made
Amount Due: $_________
Payment Type:
Cash
EFTPOS
Cheque
Voucher
Salary Package
Payroll
Visa/Mastercard *Complete item 9 at the end of this form for Credit Card payment to be processed. Alternately, you may pay
over the phone or come in to the centre to finalise your payment.
Office Use Only
Receipt Number: _______________
Receipt Date: ____/____/______
Entered In: Database ____/____/______
Entered by (Staff name):
Staff Rep: _______________
Joondalup: BLD 22, 270 Joondalup Drive, Joondalup WA 6027 Ph:6304 5000 Fax:6304 5333
Mt Lawley: BLD 21, Cnr Learoyd and Woodsome St, Mount Lawley WA 6050 Ph:9370 6700 Fax:9370 6722
Email [email protected] or visit www.ecu.edu.au/sport/khp
……………………………………………………………………………………………………………………………………………………..……
9. Credit Card Payment
Credit Card Number: (This section will be destroyed once processed, alternatively call the centre for payment over the phone)
CVV
Name on card: _____________________________________
KHP Registration Form
All printed copies are uncontrolled
Page 2 of 2
Expiry Date
Signature: _________________________________
As at June 2014
Issue 5