If you have any questions please contact  Didi on 0433 770 330  or email didi@csparks.org.au 

THE FORM BELOW IS A STANDARD REGISTRATION FORM FOR ALL ATTENDEES.

IF YOUR CHILD HAS NOT ATTENDED THE CHABAD SPARKS HOLIDAY PROGRAM AT THE S.KILDA OR CENTRAL DROP OFF IN THE LAST 12 MONTHS, YOU NEED TO FILL OUT AN ADDITIONAL ONLINE FORM BY CLICKING https://chabadyouth.hubworks.com.au  

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PARENT INFORMATION

Mothers name Mobile
Fathers  name Mobile
Mothers email Fathers email
Is the Natural Mother of the Child Jewish?
Yes No    
Are there any conversions in the family?
If yes, please specify whom and through what organisation.

 

DROP OFF & COLLECTION CENTRE:

 

 

CHILD 1 INFORMATION

Child 1 Firstname Child 1 Surname

Child 1 Name of school
Child 1 Grade (2015)
Medical Conditions
(Asthma, Diabetes etc.)
(Type N/A if none)


Please contact office about submitting a relevant management plan.

Drug/Food allergies
(Type N/A if none)

Please contact office about submitting a relevant management plan
.

Attendance:

 FULL  All days

 FULL  30 MARCH: Geelong Indoor water park - giant slides

 FULL 31 MARCH: Enchanted Maze (tree surfing for >10)

FULL  1 APRIL:  Inflatable World

 

 

 

 

Before/After care - $10 per session

If required please state when:

 



  

CHILD 2 INFORMATION

Child 2 Firstname Child 2 Surname

Child 2 Name of school
Child 2 Grade (2015)
Medical Conditions
(Asthma, Diabetes etc.)
(Type N/A if none)


Please contact office about submitting a relevant management plan.

Drug/Food allergies
(Type N/A if none)

Please contact office about submitting a relevant management plan

Attendance:

 

FULL All days

FULL 30 MARCH: Geelong Indoor water park - giant slides

FULL 31 MARCH: Enchanted Maze (tree surfing for >10)

FULL 1 APRIL: Inflatable World

 

 

 

Before/After care - $10 per session

If required please state when:

 

 

 

 

  

CHILD 3 INFORMATION

Child 3 Firstname Child 3 Surname

Child 3 Name of school
Child 3 Grade (2015)
Medical Conditions
(Asthma, Diabetes etc.)
(Type N/A if none)


Please contact office about submitting a relevant management plan.

Drug/Food allergies
(Type N/A if none)

Please contact office about submitting a relevant management plan
.

Attendance:

 

FULL All days 

FULL 30 MARCH: Geelong Indoor water park - giant slides

FULL 31 MARCH: Enchanted Maze (tree surfing for >10)

FULL 1 APRIL: Inflatable World

 

 

 

 

Before/After care - $10 per session

If required please state when:

 


 PARENTAL DECLARATION:  

I hereby authorise Chabad Sparks leaders and staff to obtain any medical care necessary for my child. I understand that in the case of emergency of any significant illness or injury, attempt will be made to contact myself when practical. I agree to pay for any cost that may occur as a result of the injury/illness.
I acknowledge my child may be participate in program activities within and outside the Program's centre. I authorise my child to participate in these activities and use the transport organised by the program.
I agree to pay for any reckless damage done by my child at the program.
I hereby authorise Chabad Sparks to photograph my child and to use the photographs at their discretion.


 I agree to the above
Name of Parent/ Guardian  
Date  

  NB:YOUR C/C WILL ONLY BE PROCESSED AFTER CHILDCARE CONTRIBUTIONS HAVE BEEN ASSESSED

PAYMENT OPTIONS 

 Credit card: VISA OR MASTERCARD ONLY 

 Cost per day: Without rebate $65/ With rebate $35

Total:         

 Card Type: Visa  Master Card

 Name on Card:  

 Card No:   Exp:  /

  HOW DID YOU FIND OUT ABOUT CHABAD SPARKS HOLIDAY BLAST? 

   OTHER: