> Wahroonga
 

Complete the form below if you would like to enrol in our next holiday clinic held at Olympic Park, Homebush.
* The fields marked with an asterix are compulsory.

Parent Details

Parent Name:
*
Parent's Gender:
* (M or F)
Telephone:
 *
Mobile:
Email:
*
Address:
Suburb:
State:
Postcode:
Child 1 Information  
Name:
*
DOB:
*
Gender:
 (M or F) *
School:
Child 2 Information  
Name:
DOB:
Gender:
 (M or F)
School:

Medical Details

1.
 Is your child/children on any long term medication?
  Child 1
  No
  Yes - please supply details:
  Child 2
  No
  Yes - please supply details:
 
2.
 Does your child / children have any known allergies or medical conditions?
Child 1
No
Yes - please supply details:
  Child 2
  No
Yes - please supply details:
   
3.
 I hereby give permission to the Moving Bodies supervisor to seek medical aid in the event of an accident, injury or illness (please tick)
Please contact the following in the event of an emergency
Initial contact:
Relationship:
Contact number:
Alternative contact:
Relationship:
Contact number:

Method of Payment

Direct deposit
  Bank: NAB | BSB No: 082 309 | Acct No: 593 754 675 | Acct Name: Moving Bodies Pty Ltd
  Please use your child's name as a reference when paying.
  I have made a deposit for the amount of $ . Reference used [child's name]: .
Cheque or money order
  Cheque or money order payable to “Moving Bodies Pty Ltd”.

Please clearly print name, address and contact number on the reverse side of cheque/money order.

Return to: Moving Bodies, 27 Glenview Road, Mt Kuring-gai 2080

 

Tel: (02) 9940 5240
Fax: (02) 9012 0895  

Office: 27 Glenview Rd, Mt Kuring-Gai
Email: info@movingbodies.com.au

 

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