1. Parent or Guardians Full Name (Emergency Contact)*

First Name Last Name

2. Relationship to child*

Parent/Guardian
Other relative
Family friend

3. Mobile Number of Parent/Guardian*

4. Email of parent/guardian*

5. The name of another Emergency Contact:*

First Last

6. The other emergency contact's Mobile number*

7. Is there a court order in place for this child*

No - there is no court order in place
Yes - there is a court order in place (please specify details below)

Please specify details of the court order*

8. How many primary aged children are you registering:*

One child
Two children
Three children

Child 1 Full Name*

First Name Last Name

Child 1 Gender*

Male
Female
Gender not disclosed

Child 1 Date of Birth (eg 05/09/2011)*

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

No
Yes

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*

Male
Female
Gender not disclosed

Child 2 Date of Birth (eg 05/09/2011)*

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

No
Yes

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*

Male
Female
Gender not disclosed

Child 3 Date of Birth (eg 05/09/2011)*

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

No
Yes

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:

CASUAL PROGRAM BOOKINGS - Please select the individual program dates that you'd like to register the children entered above for.

Twilight Delight (all primary aged kids welcome)

Dates*

Wednesdays 14 October - 2 December

Times*

3.30pm - 5.00pm

Select how many Twilight delight sessions you want to book for your child:*

Select how many Twilight delight sessions you want to book for the 2 children:*

Select how many Twilight delight sessions you want to book for the 3 children:*

Will NDIS funding be used to pay for your Jump Up Outdoors Booking?*

Yes
No

Is the child/ren you are using NDIS for, current clients of Jump Up For Kids?*

Yes
No

Please note, all families who are not current clients with Jump Up For Kids and would like to use NDIS funding, must have a phone consultation prior to their enrollment for the Jump Up Outdoors program being accepted. This is to ensure that the program fits within your child/ren's NDIS plan and that we are able to provide appropriate support for your child so they can get the most enjoyment and benefit from their visit to Jump Up Outdoors. A Jump Up For Kids OT will be in touch shortly to organise a time for a phone consult. In the meantime please complete your booking below.

Total

$ 0.00

Consent*

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Jump Up Outdoors Booking Form