Make a DONATION for Children with Disabilities
Date of Registration
CHILD'S DETAILS:
First Name *
Surname *
Date of Birth *
Address
To be eligible the child must have a physical disability – please state your child’s disability *
First time contact please attach a diagnosis letter
(file size 5MB max)
Ethnicity
Sibling names and age attending
PARENT/CAREGIVER DETAILS:
First Name
Surname
Phone / Mobile
Email
Relationship to Child
PLEASE TICK THE ACTIVITY YOU WISH TO ATTEND
LOCATION - Online
The Colours and Shapes of Winter
Wednesday 13 July 2022 : 10.30am to 12.00 noon
Yes
Inside and Outside on a Stormy Day
Wednesday 20 July 2022 : 10.30am to 12.00 noon
A $5.00 non-Refundable Registration Fee is required per child for both or one session
This can be deposited into Account Number: 12-3113-0000916-00, Reference: HolProg & your name
Upon receipt of this form the Wilson Home Trust will confirm your acceptance on the course via email
Verify that you are a human, please choose apple