School Holiday Program Enrolment Form

Child Details

Child's First Name *

Child's Last Name *

Child's Age:

Child's Date of Birth *

Gender: *

Girl

Boy

Dates for enrolment

Tuesday 5 July (8:30am - 1:30pm)

Wednesday 6 July (8:30am - 1:30pm)

Parent/Legal Guardian 1 Details

First Name *

Last Name *

Email Address *

Phone Number (mobile) *

Phone Number (other)

Parent/Legal Guardian 2 Details

First Name

Last Name

Email Address

Phone Number (mobile)

Phone Number (other)

Emergency Contacts & people authorised to collect your child/children

Emergency Contact 1

Full Name *

Relationship *

Contact phone number (mobile) *

Contact phone number (other)

Authorised to collect? *

Yes

No

Emergency Contact 2

Full Name

Relationship

Contact phone number (mobile)

Contact phone number (other)

Authorised to collect?

Yes

No

Medical Information

Does your child have any allergies or food/drug sensitivities? *

Yes

No

If YES please give details:

Does your child have an action plan? *

Yes (please provide a copy)

No

Has your child been diagnosed as at risk of Anaphylaxis? *

Yes (please provide Medical Plan)

No

Does your child take any regular medication (e.g Ventolin, etc) *

Yes (please provide details if relevant)

No

Medication details (if applicable)

Is there any other information you feel our staff should be aware of regarding your child (including but not limited to cultural and religious requirements, ADHD, Autism, fears or phobias)

Has your child received all immunisation requirements including Tetanus? *

Yes

No

Family Doctor Name *

Family Doctor Phone Number

Liability Waiver: I give permission for the staff of Kiddie Kicks Soccer to give basic first aid treatment in the event of any minor injury to my child. In the event of accident or serious illness of my child, I give permission for the staff to seek medical attention or arrange ambulance transport to hospital if considered necessary for the welfare and safety of my child. I understand that I will be required to pay for any costs associated with transport and/or treatment of my child. I agree to comply with all government requirements and regulations in relation to Kiddie Kicks Soccer, Noosa Leisure Centre and its services. I am aware that my child may be excluded from the program if he or she is displaying signs of illness particularly contagious disease. As a participant in a program run by Kiddie Kicks Soccer, my son/daughter is in good health and has my permission to participate in the soccer program. Kiddie Kicks Soccer, and its directors, employees and the facilities assume no responsibility and will not be held liable for any injuries and illness, or accidents during the class resulting in medical, dental or other expenses. I also give Kiddie Kicks Soccer permission to use my child's picture in promotion of the program in printed media and other forms of advertisement. I fully renounce all claims upon Kiddie Kicks Soccer for reimbursement for the use of this material. I, on behalf of myself, my executors, administrators, heirs, next of kin, and successors, hereby covenant to hold harmless and indemnify Kiddie Kicks Soccer and all its officers, departments, agencies, and employees from any and all claims, lessees, damages, injuries, fines, penalties, and costs (including court costs and attorney's fees), charges liabilities, or exposures, however caused, resulting from or arising out of or in any way connected to my or my family's participation in any Kiddie Kicks program/services. I also agree to be placed on the Kiddie Kicks mailing list until such time as I choose to remove myself from it. I have read, understood and agree to the terms of this Agreement.

Please read the Liability Waiver above and check the box below to acknowledge your acceptance of our terms *

I have read and understand the conditions above

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