Holiday Program Holiday Program View more about Holiday Program Order IDChild's Name* First Last Child's Birthday* Date Format: DD slash MM slash YYYY Parent / Carer Name (First & Last)*Parent / Carer Email Address* Parent / Carer Relationship to Child*Parent / Carer / Authorised Pick-Up No. 1 (Name, Phone)*Parent / Carer / Authorised Pick-Up No. 2 (Name, Phone)*Health Information & Permissions Information Form – Confidential(1) Does your child currently have any serious illness?*Yes (please provide details below at Q7)No(2) Does your child require any medical procedures to be performed on a regular basis?*Yes (please provide details below at Q7)No(3) Is your child receiving regular medication?*YesNo(4) Does your child have any allergies? Including food allergies or intolerances, reactions to insect bites, allergies to sunscreens, antiseptics, etc.*Yes (please provide details below at Q7)No(5) If the answer to Q4 above is yes, is your child’s allergic reaction likely to result in anaphylaxis?*Yes (please bring a copy of your child’s Anaphylaxis Action Plan and Epipen to the workshop)No(6) Does your child have Asthma?*Yes (please bring a copy of your child’s Asthma Management Plan and Reliever to the workshop)No(7) Please provide any details of serious illness, regular medication or medical procedures, or allergies here. Is there any other health information that we need to know?I authorise SPUFC Holiday Clinic coaches and staff to seek urgent medical, dental, or hospital treatment, which may include transport by ambulance, should my child be injured during the SPUFC Holiday Clinic.*YesI agree that photographs and videos taken during SPUFC Holiday Clinics, may be used by SPUFC for promotional purposes, in general group situations and without names being associated with those photographs and videos. Approval will be sought from parents for the use of any photographs or videos that depict individuals. Promotional methods may include newsletters, website or social media platforms, and flyers.*YesNoPlease provide any additional information that will assist SPUFC Holidays Clinics to meet your child’s needs while participating in activities.SPUFC memberSelect DaySPUFC member : One day ($ 60)SPUFC member : Two days ($ 100)Select your attending dayFirst DaySecond DayNon-SPUFC memberSelect DayNon-SPUFC member : One day ($ 70)Non-SPUFC member : Two days ($ 120)Select your attending dayFirst DaySecond DayTotal $ 0.00 EmailThis field is for validation purposes and should be left unchanged.