July 2022 School Holiday Activity

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

Yes

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