School Holiday Program Enrolment School Holiday Program Enrolment Page 1 Page 2 Page 3 Page 4 Page 6 Page 7 Web Site Child's Details Child's Surname * Child's Given Name(s) * Preferred name Date of Birth * Gender * Male Female Home address * Suburb * State * Postcode * Medical History and Information Does your child have any current health care needs or medical conditions? * Yes No Does your child have any allergies? * Yes No Does your child have any dietary requirements (including cultural/religious requirements)? * Yes No Has your child been diagnosed at risk of anaphylaxis? * Yes No Has your child been diagnosed with asthma? * Yes No Anything else you would like to tell us about your child's health: Parent/Guardian 1 Details Parent's Surname * Parent's Given Name(s) * Relationship to child * Mobile number * Home phone Email address * Parent/Guardian 2 Details (optional) Parent's Surname Parent's Given Name(s) Relationship to child Mobile number Home phone Email address Emergency Contact Emergency Contact Full Name * Relationship to child * Street Address * Suburb * State * Postcode * Mobile Phone * Home Phone Work Phone I give permission for the above emergency contact to: * Collect the child from Mochi Music. Authorise medical treatment of, or administration of medication to the child. Medical Contacts Doctor's Full Name Medical Practice Phone number Email Street Address Suburb State Postcode Do you give permission for photographs and video of your child to be featured on the Mochi Music website and associated social media sites? * Yes No
