Konini Holiday Programme

Enrolment Form

Children’s Details

Full Names of Children Age Date of Birth

Antonia Lopez Zapata
6 25.11.2017

Child’s Home Address

School Ellerslie Primary School

Days Attending (please tick or circle)

Monday Tuesday Wednesday Thursday Friday

Drop off time 8:00 to 8:30 around Pick up time. 4:30 to 5:00 PM

Notes

Main Parent/Caregiver Contacts

Full Name Francis Zapata Marin

Email francis.zamarin@gmail.com

Place of Work Newmarket

Work /Mobile/Home Phone 0221658807

Second parent/caregiver details

Full Name Juan LOpez

Email JUANLOPEZNZ1@GMAIL.COM

Place of Work near Airport

Work/Mobile/Home Phone 0211856411

Emergency Contacts

(Please enter details for two adults other than parents/caregivers who can be contacted in case of
emergency)

Full Name (1) Jimena Pena

Phone Number 0225681790

Relationship to your children Friend

Full Name (2) Victoria Castro

Phone Number 0220688021

Relationship to your children Friend

Other People authorised to collect your children.

Full Name/s

Relationship to your children

Instructions/Notes

People not authorised to collect your children.

Names

Family Doctor

Name

Phone Number

Additional Information

Does your child/ren have any health needs we should be aware of? (e.g., food allergies,
food requirements, asthma, medical conditions etc). NO

Is there anything else we should know about to take good care of your child? (e.g.,
custody arrangements, special needs, behavioural issues etc). NO

I give permission to use public transport or walking trips for excursions stated in the
programme of events. Yes No

Permission for photos to be taken. Yes No

Permission to walk home. Yes No

Permission to walk to and from the car park without parent Yes No

Sunblock use? Yes No

Parent Contract

Please sign this contract to complete enrolment. If you have any questions about the
programme or wish to see a copy of the programme policies prior to signing, please do
not hesitate to ask a member of staff.

• I/We agree and acknowledge:

- I have read and understand the enrolment information.
- I agree to allow my child to attend the Konini holiday programme understanding
the care is provided by a Staff ratio of 1-10
- I give permission for Programme staff to administer first aid and seek
emergency treatment if necessary.
- I will notify the Programme supervisor of any changes to enrolment information
in a timely fashion.
- I agree to pay fees as stipulated in the fees policy.
- I understand that days and hours booked will be charged for that.
- If any outstanding debt is longer than 60 days, the account will be passed onto a
collection agency and additional fees will be added later.
- I have read and signed the Parent Contract/Information Sheet

All care will be taken to provide supervision of children attending the programme in
accordance with programme policies and procedures.

Name of parent: Francis Zapata

Signature of parent:

Date: 15.12.2023

Please be aware that Te Kahui Kahu (Ministry of Social Development MSD), will have
access to personal information for social services accreditation purposes.

Privacy Act 2020: The information that you have supplied is necessary for the safe and
effective operation of the OSCAR programme.

All personal information requested will be destroyed at the completion of your child’s
time in the programme. You are welcome to review information pertaining to your child’s
enrolment at any time.