1. Your Name*

First Name Last Name

2. Name of person bringing the child (if you are not bringing them)

First Last

3. Mobile number of person bringing the child*

4. Email*

5. How many 2-4 year old children will be participating:*

Child 1 Full Name*

First Last

Child 1 Gender*

Child 1 age*

Does Child 1 have any medical and / or behavioural conditions that may affect their participation in the Jump Up program?*

For Child 1 please describe the medical and / or behavioural condition and associated management plan:

For Child 1 List any dietary or other considerations that affect participation in the program

Child 2 Full Name*

First Name Last Name

Child 2 Gender*

Child 2 age*

Does Child 2 have any medical and / or behavioural conditions that may affect their participation in the Jump Up program?*

For Child 2 please describe the medical and / or behavioural condition and associated management plan:

For Child 2 List any dietary or other considerations that affect participation in the program

Child 3 Full Name*

First Name Last Name

Child 3 Gender*

Child 3 age*

Does Child 3 have any medical and / or behavioural conditions that may affect their participation in the Jump Up program?*

For Child 3 please describe the medical and / or behavioural condition and associated management plan:

For Child 3 List any dietary or other considerations that affect participation in the program

Term*

3 children in the 8 week Junior Rangers program*

Price: $ 600.00

2 children in the 8 week Junior Rangers program*

Price: $ 400.00

1 child in the 8 week Junior Rangers program*

Price: $ 200.00

Total

$ 0.00

Consent*

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Junior Ranger registration form