Cnr Kiora Road & Adina Street, Miranda 2228 NSW   -  (02) 8517 0841

Kids Holiday Club Registration Form

Miranda Congregational Church
Wed 12th - Fri 14th July 2017, 9am to 3pm
To Register - Fill in the form below
Or print a copy and post it to Mrs Frederika Olthof: 2 Badto Ave Gymea 2227
Or bring the completed form with you when you come.
For more information email kidsholidayclub@mirandacong.org.au

  • Surname *
  • Parent (s) Firstname *
  • Street Address *
  • Suburb *
  • Postcode *
  • Phone (H) *
  • Phone (W)
  • Mobile
  • Email
  •  
  • Emergency Contact Information
  • Emergency Contact Name *
  • Relationship to Child/Children *
  • Emergency Contact Ph *
  •  
  • Name (s) of Children attending and their year at school *
    eg John Smith Year 3
  • Any Medical / dietry information you feel the leaders should know
  • Permission to attend *

Whilst I understand that reasonable care and control will be taken to protect my child(ren) from injury, I accept that Miranda Congregational Church, its staff or volunteers cannot be held responsible for any accident or loss. I also give my permission for medical/ambulance assistance in case of emergency and agree to pay such costs as may be incurred. I also give permission for my son/daughter to be videoed/photographed (A short video presentation will be made of the Kids Holiday club highlighting the events of the week, which will be screened on the premises only).