ESSINGTON Program Enrollment Form ; DetailsChild 1:* Date of Birth* Child 2 (if applicable): Date of Birth Child 3 (if applicable): Date of Birth Address* Email Address* Person to be contacted*Emergency Contact No.*Booking Contact Name I, the above mentioned name, give consent for my child to participate in the TEMS Essington Programas programmed and conducted by Ben McLachlan and any other employees/contractors ofTEMS. I authorize Ben McLachlan and any assistant trainers of TEMS to obtain any medical assistance, which they may deem necessary should an accident occur, and agree to pay all medical expenses incurred. I submit the attached medical information about my child and include other relevant information and details of limitations. I further authorize qualified practitioners to administer anesthetic if such an eventuality arises. I agree to a cancellation fee of $35 if less than 6hours’ notice is given and 100% of fee if less than 2 hours’ notice is given. I agree that payment will be made in full prior to my child beginning the above mentioned program. Location: 110 Old McMillans Rd, Coconut Grove Cost for Holiday Program: $60 per day or $250 per week Cost for Essington Holiday Program: $50 per dayMedical InformationMedical Condition - Please Specify Child 2 Child 3 Other Medical Information* Essington School Holiday Program (9th December - 12th December) Monday 9th December Tuesday 10th December Wednesday 11th December Thursday 12th December How did you hear about our Program? School newsletter Facebook/Instagram Have been before Friends Other Approximate Drop Off Time Approximate Pick up Time PERMISSION TO USE PHOTOSI grant permission to TEMS to use images of:Parent's Name* Children's Name* Name of person providing permission to use photos* Such use includes the display, distributions, publications, transmissions or otherwise use of photographs, images and/or videos taken for use in materials that include but may not be limited to, printed materials such as Brochures, Newsletters, Videos and digital images used on TEMS’ website and other Social Media pages, such as Facebook and Instagram.Permission Grant for photos I grant permission for the use of photos of myself and my children to be used I deny permission for the use of photos of myself and my children to be used **Please notify TEMS in writing if you would like to withdraw your permission for the use of images.Read Terms of Site* I have read and understood the terms of this site. CAPTCHA
