Spark Plugs Enrolment Form

Term 4 2018 - Enrolment Form

If you would like your child to participate in a Spark Plugs Program, please complete this online enrolment form.

Term 4 2018 Clubhouse details are:

Day: Tuesday afternoons - commencing 16th October 2018

Time: 3.30pm - 5.00pm

Venue: Sacred Heart Parish Hall, 143 Murwillumbah Street, Murwillumbah

Cost: $170 per term (includes afternoon tea)

All staff and volunteers have current Working with Children Clearances.

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* 1. Parent/Guardian Details:

Name

Email Address

Phone Number

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* 2. Child's Details:

First Name

Surname

Age in 2018

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* 3. Child's Details:

First Name

Surname

Age in 2018

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* 4. Child's Details:

First Name

Surname

Age in 2018

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* 5. Child's Details:

First Name

Surname

Age in 2018

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* 6. Does your child have any allergies? (Please provide specific details)

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* 7. Does your child have any special dietary requirements? (please provide specific details)

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* 8. Emergency contact/ authorised to pick up my children #1 (please provide two additional people)

Name

Email Address

Phone Number

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* 9. Emergency contact/ authorised to pick up my children #2

Name

Email Address

Phone Number

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* 10. Parental / Legal Guardian Consent - Terms of Service:

As the Parent or Legal Guardian of the young person(s) named, having completed the online Enrolment Form, I thereby give permission for my child/ren to participate in the Spark Plugs Program having read and giving my consent to following:

I give permission for the facilitator(s) of the Spark Plugs Innovation Club to implement Spark Plugs Program rules and code of conduct and/ or to take other reasonable measures to ensure the successful conduct of the Program as well as the safety and wellbeing of all members.

In the event of any injury or illness to my child, I authorise the facilitator/s of the Spark Plugs Program to apply or arrange first aid and to arrange examination by a registered medical practitioner. If contact with me is impractical or impossible, I further authorise the facilitator/s to arrange whatever medical treatment the registered medical practitioner considers necessary at the time. I agree to pay all medical expenses incurred on behalf of my child.

I agree to release Spark Plugs Innovation Club and/or its employees and volunteers from any liability to my child or myself in relation to an illness or injury that my child may suffer, and for loss or damage to property in connection with the Spark Plugs Program, except to the extent that the liability arises as a result of negligence on behalf of the Spark Plugs Innovation Club and /or its employees and volunteers.

I acknowledge and agree that Spark Plugs Innovation Club collects personal information for the purposes of conducting the activity and that the organisation may provide this personal information for the purposes of conducting the activity to authorised employees for the purpose of administering, evaluating and reporting on the above named activity.

Spark Plugs Innovation Club wishes to record images of the Spark Plugs Program, including the young people participating in the activity. These images may be used in publications, posters, events, promotional material/ broadcasts, reporting materials and websites in any form of the media. Unless you do not grant permission on the Media Consent Form, images/video may be taken of your child and used for the above purposes.

I have read the Spark Plugs Terms of Service and give consent for my child / dependent to participate in the Spark Plugs activities under the supervision of Spark Plugs facilitators.

An enrolment confirmation email will be sent to the email address provided with more details, including how to make payment for the term. Thank you and we look forward to seeing you at Spark Plugs Innovation Club!