Childs name

Date of birth Description of medication

Age

Health conditions/ other relevant information

Year at school

Class rm

Ethnicity(optional)

Gender

M/F

Childs name Dosage Family doctor Doctors ph number Any other info

Date of birth

Age

Year at school

Class rm

Ethnicity(optional)

Gender

M/F

Childs name

Date of birth

Age

M
8-9am Breakfast $8/day (Breakfast included) 9am-3pm $90.00/week $20/day 3pm-5.30pm $12/day Family discounts may apply Discounts for 8-5.30, m-f may apply Ask Emma (The Manager) on enrolment Number of children

TH

Year at school

Class rm

Ethnicity(optional)

Gender

M/F

Caregiver(s)

Relationship

Street address

Phone (wk)

Phone (hm)

Relationship to child

Fees must be paid in advance for your child to attend. Please ask for a WINZ form when enrolling .WINZ forms need to be handed in to WINZ before the programme begins.

Must be different to Caregiver info

Emergency contact (2)

Phone

Anyone legally not allowed access: (If this person is a legal guardian-proof must be given)

2 Programmes will be provided. The younger programme for year 1-5 children will be based at Christchurch East School Amped rooms. The older programme for year 6-8 children will also be based at the school, but will spend much of the time out on van excursions and on the church site.

Manager: Emma Tovey

emma@otbc.org.nz 0277806629

This programme is run by the same staff as the ROCKET programme, but is not the same programme

Relationship to child

Amped

Phone

Holiday Programme 1-5 October 2012

Emergency contact (1)

Total cost:

WINZ subsidies are available

Based at Christchurch East School Run by Newell House Trust In association with Oxford Terrace Baptist Church

Suburb

Mobile

Email

I understand that any changes to my child/rens attendance for Amped Holiday Programme, ideally needs to be communicated to the Manager by phone, email or text by 9.30pm. I agree to my child/ren travelling by vans for any Amped activities on the advertised plan. I understand that Amped will be responsible for my child/ren from the time they are signed in on arrival at Amped until they are signed out on the roll. I understand anyone picking up my child/ren including myself may be asked for photo I.D at any time. I agree to my child/ren watching PG rated movies if they are deemed as age-appropriate by Amped. I agree to Amped Staff administering the medication as detailed by myself in the Medical Action Plan and Administration of Medication form which I have completed in full and signed. I agree to Staff seeking medical assistance for my child/ren as necessary. Any cost incurred in obtaining such aid will be met by me. I agree to photos and videos of my child/ren taken at Amped being used for Amped publicity. I agree to my child/ren being disciplined by the Supervisor, according to the discipline procedure. I agree for Amped Staff to apply sun block as needed throughout the day. I give permission for my child/ren to go on local walks with Amped. I understand there will be a late fee charged to my account if I collect my child/ren later than 3.00pm or 5.30pm (depending on the programme enrolled in) of $10. I agree that if I fail to pay my account and Amped has to involve a debt collection agency, the collection costs incurred will be added to the total of my account. I am aware that I will be charged for the days my child is booked in for, even if my child is absent. I understand that Amped has the right to suspend or terminate my enrolment due to lack of payment or due to unacceptable behaviour by my child/ren. I understand that I will be contacted to collect my child/ren if they become sick during Amped. Im responsible for notifying Amped of any changes in circumstance or contact/medical details. All care will be taken to provide supervision of children attending Amped in accordance with the Programme policies and procedures. I acknowledge however, in signing this form that neither the Staff nor management of Amped will be liable for any loss or damage (by way of accident, injury, theft or otherwise) arising out of attendance at Amped. The Privacy Act 1993. Amped wishes to collect personal details for the purpose of Programme registration and supervision. This information will be accessible to Amped Staff and is intended for Programme Supervisors. You have the right to access and check any details you have supplied. This information is not required by law, however, if refused, it may be necessary to decline your enrolment. The information on this form may be viewed by Child Youth and Family. Signed (Parent/ Caregiver) Date:

Bank account 01-0798-0083959-00(Please include name) Paying by cheque Please make the cheque out to Amped. Enrolment Enrolment is finalised upon completion of an enrolment form, the signing of this brochure and payment of the fees. Please inform Amped Staff of any relevant changes to your enrolment details. It is crucial we have up to date information. Lunch Please provide a packed lunch for your child each day Absences Please inform us by 9.30am if your child will not be attending. Collecting your child If a person arrives to collect your child whose name is not on the enrolment form, we are obliged to keep your child in our care until you have been located for consent. We would appreciate prior notification from you on this matter. Please remember Amped closes at 3.00pm. A late fee of $10.00 will be charged if the child is collected after this time. Signing your child in/out Each day when you bring/collect your child, it is essential that you sign your child in/out of the daily roll book. Fees Fees are our only source of income. To operate efficiently we require that fees be paid in advance. Receipts will be given on request. Management reserves the right to terminate your childs place in Amped programme if fees are not paid. Sickness You may be contacted to collect your child early if they become unwell. Please do not send your child to the programme if they have been vomiting or had diarrhoea in the last 24 hours. Notices will be posted at Amped for parents in the event of infectious diseases having been present at Amped. Behaviour If we feel we are unable to keep your child (or other children) safe due to your childs behaviour, we reserve the right to contact you for early collection. Trips Trips will be by van and will be advertised soon. On these days, it may not be practical to collect your child earlier than 3pm unless from the trip destination itself. This programme is Managed by Emma Tovey, and Supervised by several staff members over the age of 18years old. Volunteer leaders over the age of 14 will also be present. All staff are police checked, and all volunteers are reference checked and well supervised. Content Alongside great recreational, creative and fun activities, at AMPED we incorporate Christian values into the way we do things and will embrace themes such as God loves us, anyone can talk to God, and God asks us to treat each other nicely. If you have any questions about this please talk to Emma.