Homework Hub Enrolment Form

Homework Hub

Enrolment Form

Program:

Homework Hub

Swim Program

PortWorx

Parent/Guardian Details

Name

First Name

Last Name

Contact Number

Address (next terms enrolment information will be sent to this address):

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child/Participant One

Name

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Age

Conditions requiring special consideration (medical / physical / allergy):

Child/Participant Two

Name

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Age

Conditions requiring special consideration (medical / physical / allergy):

Child/Participant Three

Name

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Age

Conditions requiring special consideration (medical / physical / allergy):

Child/Participant Four

Name

First Name

Last Name

Date of Birth (DD/MM/YYYY)

Age

Conditions requiring special consideration (medical / physical / allergy):

Country you were born in

Languages spoken at home

Do you identify as Aboriginal and/or Torres Strait Islander?

Aboriginal

Torres Strait Islander

Both Aboriginal and Torres Strait Islander?

I give permission to Port Kembla Youth Project (PKYP) and Communities to take, use and publish photographic and video images and sound recordings in any format.

Yes

The information that we collect from you on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. Port Kembla Youth Project (PKYP) collect and store your personal information for their records. By using this form, you are consenting for PKYP to store your personal information.

Homework Hub

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