Parent/Guardian Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Gender *

Male

Female

Does your child have a medical condition/health concern that needs to be managed during the school day?

Select the appropriate box or if not mentioned please specify

Allergies

Asthma

Diabetes

Seizure disorder (e.g. epilepsy)

Hearing impairment

Physical disability

Speech impairment

Visual impairment

Intellectual/learning impairment (e.g. dyslexia)

Acquired brain impairment

Mental health or behaviour issue (e.g. depression, ADHD)

Emergency Contact *

Must be different to parent/guardian named above

First Name

Last Name

Preferred Session *

We will try our best to accomodate for your preferred time session, however, this is subject to availability and cannot be guaranteed.

11:15am - 12:15pm

12:15pm - 1:15pm

Parent Contract *

I have read the Parent Contract and accept all terms and conditions outlined.