Parent/Guardian Name

Full name

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact Name

Please provide a secondary adult contact to be used as an emergency contact for all participants.

Emergency Contact Phone:

Child 1 - Name

Child 1 - Date of Birth

Child 1 - Pronouns

Child 1 - Medical Information

Is there anything that we should know about the Childs medical history? Does the child have any allergies? Does the child have any learning difficulties?

Child 2 - Name

Child 2 - Date of Birth

Child 2 - Pronouns

Child 2 - Medical Information

Is there anything that we should know about the Childs medical history? Does the child have any allergies? Does the child have any learning difficulties?

Child 3 - Name

Child 3 - Date of Birth

Child 3 - Pronouns

Child 3 - Medical Information

Is there anything that we should know about the Childs medical history? Does the child have any allergies? Does the child have any learning difficulties?

What days would you like to book?

Please check all boxes of days you wish to book. For half day bookings please use the "Booking Comments" field below to specify what days you would only like half days.

Booking Comments

Please specify anything like half day requests, or general comments about your booking here.

Terms & Conditions

Please check all boxes to indicate that you have read all of the T&C's.

PAYMENTS & BOOKINGS - Bookings are not confirmed until payment has been made. Bookings that have an outstanding balance may be cancelled to allow for new bookings.

CANCELLATION & REFUNDS - Cancellations must be made in writing. Family Credit will not be given if a booking is cancelled within 24 hours of the booking start time. If the center needs to cancel the program Family Credit will be applied for any missed bookings. Refunds are only permitted in extreme circumstances.

EARLY/LATE ATTENDANCE - The action break program begins at 8:30am and finishes at 4:30pm. Drop off and pick up is expected within these times. An additional fee of $30 per half hour will occur for any children dropped off early or picked up late.

BEHAVIOUR MANAGMENT - The YMCA reserve the right to expel a participant if their behaviour jepordises the safety and wellbeing of staff and other childen. Bullying will not be tollerated. If behavioral issues arise, children will be removed from the group for a short period of time, if it continues parents will be contacted to collect child.

ACTIVITY PARTICIPATION - I give consent for my child to participate in all activities organised by the YMCA and am aware of the inherent physical risks in partaking in all activities. Activities are subject to change without notice.

FIRST AID PERMISSION - In the event of accident or illness, I authorise medical treatment for my child and the associated costs. Food allergies need to be noted above, together with any procedures that need to be taken.

EXCURSION PERMISSION - I give permission for my child to attend any excurisons that they have been booked for. I understand that they will safely travel too and from the excursion location by bus.

PERSONAL ITEMS - I have read and understood what children should and shouldnt bring to the Action Break Program. I understand that The YMCA accept no responsibility for lost or damaged items such as clothing, money, electronic devices etc.

PHOTO CONSENT - I understand that The YMCA may take photographs and videos of the children at Action Break. I understand that these may be used for advertising purposes. You will be required to provide photo consent when signing in daily.

Action Session	$35/child	Morning 8:30-12:30pm, Afternoon 12:30-4:30pm
Action Day	$65/child*	8:30am-4:30pm *$80 on incursion and excursion days
Action Week	$320	Monday-Friday *Inclusive of all incursions & excursions

Kilgariff Recreation Centre

Action Break

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