ACG Strathallan Summer Holiday Programme Enrolment Form Please complete and return this form to Strathallan@acgedu.com by 1st November 2020 to participate in the Summer Holiday Programme
Student Information Student full name (Last/First) Emergency contact number
ACG Student ID (if applicable) NZ Address
Caregiver Email address
Current School
Caregiver phone number
Student Mobile number
Do you live in homestay
ᵼ Yes
ᵼNo
Student Doctor
SUMMER HOLIDAY PROGAMMES (tick the box to indicate which programme/s you would like your child to attend) Programme Name
Programme dates
Price
Pre-Christmas Programme
Tuesday 8 —Friday 18 December 2020
ᵼ $750
New Year Programme
Tuesday 5 —Friday 15 January 2021
ᵼ $750
Total amount: $
Bank details: Bank Account Name: ACG Schools Limited Bank Account Number: 03 0826 0168838 00 Swift Code: WPACNZ2W Bank: Westpac New Zealand Limited Bank Branch Address: Level 3, 16 Takutai Square, Auckland 1010, New Zealand Reference Student ID & Student Name
0FEJDBM ,OGPSNBUJPO Is your child presently taking tablets and /or medicine
рх╝ Yes
рх╝ No
(if yes) please state the name of the medication and the dosage ____________________________________________________________________________________ рх╝ Yes
Has your son/daughter been on any medication during the last month?
рх╝ No
(if yes) please state the name of the medication and the dosage ____________________________________________________________________________________ рх╝ Dizzy Spells рх╝ Heart Condition рх╝ Asthma рх╝ Blackouts рх╝ Migraine рх╝ Diabetes рх╝ Fits of any kind
Please tick if your child suffers any of the condition(s) listed
Allergies to рх╝ Penicillin рх╝ Food рх╝ Medication рх╝ Other / including environmental e.g. sprays, plants, bees/wasps etc. Specify:______________________________________________________________________________ What special care / treatment is recommended? ____________________________________________________________________________________ Any dietary requirements for the EBZ USJQT? ____________________________________________________________________________________
Has your child received a tetanus vaccine in the last 5 years?
рх╝ Yes
рх╝ No
рх╝ Unsure
Do you give permission for your son/daughter to be given a tetanus injection or other medical procedures if the doctor recommends it? рх╝ Yes
рх╝ No
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Signature of parent /legal guardian
Signature of Student
Date of Signature
DD
MM
YY