School Holiday Clubs Registration

Your Child's Name*

Date of Birth*

Does your child have any relevant diagnoses? (e.g. Autism, ADHD, Apraxia, Dyslexia) If yes, please let us know here.*

Address

Suburb

Parent/Carer 1 Full Name*

First Last

Parent/Carer 1 Relationship to child

Parent/Carer 1 Contact Number

Parent/Carer 1 Contact Email*

Parent/Carer 2 Full Name

First Last

Parent/Carer 2 Relationship to child

Parent/Carer 2 Contact Number

Parent/Carer 2 Contact Email

Which holiday group program would you like to enrol your child in?*

What are your main areas of concern/goals you would like to see addressed in this program? Please list below.

Current services: Please list any services or providers your child is working with.

Email

This field is for validation purposes and should be left unchanged.