Holiday Activities Booking Form — Potential Therapy Services

HOLIDAY ACTIVITIES BOOKING FORM

Please complete this form if you would like to request a place in one of our holiday activities. We will be in touch to confirm your booking.

Child's full name

Date of Birth

YYYY

Parent/Guardian's full name

Relationship to child

Contact Email

Contact Phone

(###)

###

####

Please tick the activity you would like to book:

Young Explorers (3-6yrs) - Wednesday 25th September at 9.30am

Ninja Warrior (7-12yrs) - Wednesday 25th September at 2pm

If your child has any medical conditions and/or allergies, please provide details below

Does your child have a Medical Emergency Response Plan (eg ASCIA Action Plan for anaphylaxis)? If yes, please provide a copy on arrival at the clinic

Please provide any other information you would like us to know about your child.