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HOLIDAY PROGRAMME ATTENDING: Stokes Valley Centre Lower Hutt

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HOLIDAY PROGRAMME ATTENDING: Stokes Valley Centre Lower Hutt KIDS DOMAIN APRIL HOLIDAY PROGRAMME 2012 STOKES VALLEY – Room 12, Tui Glen School, Stokes Valley LOWER HUTT - Hutt Art Building, Corner Myrtle & Huia Street, Lower Hutt Phone: 027 4749573 (Lower Hutt Supervisor) 021 0793862(Stokes Valley Supervisor) Email: [email protected] Website: www.kidsdomain.biz ENROLMENT FORM IS TO BE FULLY COMPLETED OR IT WILL NOT BE PROCESSED!!! HOLIDAY PROGRAMME ATTENDING: Stokes Valley Centre Lower Hutt Centre (please tick one) Child’s Name: .................................................................................................... Female / Male ........................................ Age: ................... Mothers Name: ........................................................................................ Fathers Name: ................................................................................. Home Address: ..................................................................................................................................................................................................... Home Phone: ................................................................. Work Phone: ................................................................. Mobile: .................................................................................. Email: ...................................................................................................................... Emergency Contact Person: .................................................................................................. Phone: ................................................................. Emergency Contact Person: .................................................................................................. Phone: ................................................................. Child’s Doctor/Medical Centre (or last doctor seen): ............................................................................................................................................ Person/s Authorised to collect child/ren: ............................................................................................................................................................... Personal Info we should know (e.g custody arrangements, special needs) ............................................................................................................ Medical Conditions/Allergies: .................................................................................................................................................................................... Special Instructions (e.g allowed to walk to parents work at 3.30pm) ................................................................................................................. Will you be applying for a WINZ subsidy NO YES (IF ‘YES’ PLEASE TICK WHICH RATE APPLIES TO YOU) Children in Your Care Your Households Weekly Income Before Tax 1 Child $1200.00 and under $1200.00 - $1299.00 $1300.00 - $1399.00 2 Children $1380.00 and under $1380.00 - $1489.00 $1490.00 - $1599.00 3 or more Children $1540.00 and under $1540.00 - $1699.00 $1670.00 - $1799.00 DAY ACTIVITY DROP PICK DAY ACTIVITY DROP PICK OFF UP OFF UP TIME TIME TIME TIME Tues 10 April Aboriginal Art Wed 11 April Biscuit Decorating Thur 12 April Laserforce Wellington Fri 13 April Swimming @ Naenae Pools Mon 16 April Make Lolly Leis Tues 17 April Lower Hutt & Stokes Valley Fun Day Wed 18 April Movies at Queensgate Thurs 19 Hutt Indoor Sports Cinemas April OR Junglerama (circle one) Fri 20 April Swimming @ Naenae Pools By signing this registration form, you agree/accept Kids Domains policies & procedures/terms and conditions (full copy available at centre) I have read the information given in this enrolment and also give consent for any excursions away from the centre. Signed: ………………………………………. Print Name: ……………….……….…….……. Date: …….………………….. OFFICE ONLY TOTAL FEE PAYABLE $ WINZ PAPERWORK RECEIVED YES OR NO PARENT PAYMENT RECEIVED WINZ PAYMENT RECEIVED $…………………….... date …………….……. $…………………….... date …………….……. $ ………………….….. date ………………….. $ ………………….….. date ………………… $………………….…... date ………………….. $………………….…... date ………………….. $………………….…... date ………………….. SCHOOL HOLIDAY CARE SCHOOL HOLIDAY PROGRAMMES Servicing Maungaraki School, Waterloo School, Our Lady of the Rosary School Waiwhetu, Gracefield School, Hutt Central School, Petone Central School, Wilford School, Randwick School, SS Peter and Paul School, Arakura School, Wainuiomata Primary School, Avalon Intermediate, Avalon Primary School, Belmont School, Boulcott School, Dyer Street School, Epuni School, Fernlea School, Konini Primary School, Koraunui School, Maranantha Christian School, Naenae Intermediate, Naenae School, Normandale School, Pomare School, Pukeatua Primary School Wainuiomata, Raphael House Rudolf Steiner, Rata Street School, Sacred Heart School Petone, San Antonio School, St Bernadettes School Naenae, St Bernards College, St Claudine Thevenet School, St Michaels School Taita, Taita Central School, Tawhai School, Tui Glen School, Wainuiomata Intermediate, Wa Ora Montessori School, Wilford School, Eastern Hutt School, Kelson School, Korokoro School and Hutt Intermediate School the wider Lower Hutt school community. .
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