Wander Zone Activity Day Registration

Name of Child *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Parent/Carer *

First Name

Last Name

Phone for Parent/Carer *

(###)

###

####

Second contact name *

First Name

Last Name

Second contact number *

(###)

###

####

Days Attending

Saturday 16th August

Sunday 17th August (Am and Picnic)

Photo/Video permission *

No image will be used outside of Church (e.g. on the Church web site) without checking first.

I give permission

I DO NOT give permission

Emergency Treatment Consent *

In an emergency and/or I am not contactable, I am willing for my child to receive necessary hospital or dental treatment including anaesthetic

Yes

No

Confirmation *

I consent for my child to take part in activities provided and will pay the agreed admission fee on arrival.

Confirmed