Enrolment Form

Date of Enrolment*

Name of Child*

Gender*

Male
Female

Date of Birth*

Ethnic Origin*

Iwi affiliation (if NZ Maori is ticked) Up to 3 iwi affiliations may be identified

Home Details

Name of Parent/Caregiver/Guardian*

Parent/Caregiver/Guardian Address*

Street Address Address Line 2 City ZIP / Postal Code

Parent/Caregiver/Guardian Home Number

Parent/Caregiver/Guardian Mobile Number

Parent/Caregiver/Guardian Email Address*

Enter Email Confirm Email

Emergency Contacts

Emergency Contact Person 1*

Emergency Contact Person 1 Phone Number*

Emergency Contact Person 2*

Emergency Contact Person 1 Phone Number*

Enrolment Information

Sessions you would like to Enrol for*

Tuesdays 9.00am - 12.30pm
Wednesdays 9.00am - 12.30pm
Thursdays 9.00am - 12.30pm
Fridays 9.00am - 12.30pm

These will be confirmed once the enrolment process is completed.

Is your child enrolled at any other ECE services*

Yes
No

Pleas Note: If your child is enrolled at another service i.e. home based care, for the same time period as you attend this playgroup then we cannot claim any funding for your child. Please discuss with our playgroup coordinator.

Permission for my child to be photographed while attending playgroup*

I give permission
Do not give permission

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