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