ACG Tauranga School Holiday Programme Application Form 2020

ACG Tauranga Summer Holiday Programme Enrolment Form Please complete and return this form to Tauranga@acgedu.com by 11th 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

▢ Yes

▢No

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

A Kiwi Christmas

Monday 14 - 18 December 2020

▢ $390

Sherlock Holmes

Tuesday 5 - Friday 8 January 2021

▢ $390

Summer in the Bays

Monday 11 - Friday 15 January 2021

▢ $390

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

Medical Information

Is your child presently taking tablets and /or medicine

▢ Yes

▢ No

(if yes) please state the name of the medication and the dosage ____________________________________________________________________________________ ▢ Yes

Has your son/daughter been on any medication during the last month?

▢ No

(if yes) please state the name of the medication and the dosage ____________________________________________________________________________________ ▢ Dizzy Spells ▢ Heart Condition ▢ Asthma ▢ Blackouts ▢ Migraine ▢ Diabetes ▢ Fits of any kind

Please tick if your child suffers any of the condition(s) listed

Allergies to ▢ Penicillin ▢ Food ▢ Medication ▢ Other / including environmental e.g. sprays, plants, bees/wasps etc.

Specify:______________________________________________________________________________ What special care / treatment is recommended? ____________________________________________________________________________________ Any dietary requirements for the Years 1 to 4 morning trip ? ____________________________________________________________________________________

Has your child received a tetanus vaccine in the last 5 years?

▢ Yes

▢ No

▢ Unsure

Do you give permission for your son/daughter to be given a tetanus injection or other medical procedures if the doctor recommends it? ▢ Yes

▢ No

Parent/Caregiver - ACG Agreement I acknowledge and agree that I have read and understood the enrolment information found on the ACG Summer Holiday Programme ("Holiday Programme") flyer as well as ACG's standard Contract of Enrolment. I agree that the Contract of Enrolment will, where relevant, apply to students' participation in the Holiday Programme (and agree to be bound by those terms). 2. I understand that there are risks associated with involvement in the Holiday Programme, including that certain activities will be managed by a third party service provider, and by enrolling a student in the Holiday Programme I consent to their participation in those activities. Whilst ACG has selected the third party service providers in accordance with its usual policies, I acknowledge and agree that, to the extent permitted by law, neither ACG nor anyone associated with ACG is responsible for the provision of activities managed by the third party service providers and does not accept any liability arising from or in connection with those activities (including but not limited to any injury or accident a student experiences while participating in the Holiday Programme or for any damage or loss to students' personal belongings). Students must comply with any notice or direction given by ACG or third-party provider staff relating to the Holiday Programme and must avoid behaviour that could cause injury or harm to other participants in the Holiday Programme or to property. 3. The school has my permission to arrange any necessary urgent medical treatment at my cost or contact a student’s insurance company for a claim. 4. I will notify the school of any changes to our details (including any changes in medical or other circumstances) in a timely fashion. 5. I understand photos/videos taken during the Holiday Programme will only be used for advertising on the ACG website, newsletter, and social media for marketing purposes. 6. I agree to pay the fees for the Holiday Programme as stipulated in the Holiday Programme flyer. If I choose to cancel or withdraw my enrolment in the Holiday Programme, no refunds will be offered.

Signature of parent /legal guardian

Signature of Student

Date of Signature

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