Netta Skills Registration Term 3 2018

Question Title

1. Contact Information (Parent)

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

2. Contact Information (Child)

Name

Question Title

3. Date of Birth (Child Participating)

Date / Time

Date

Question Title

4. Has your child attended a NetSetGo program before?

Yes

Other (please specify)

Question Title

5. Medical Information (Please select any if applicable)

Asthma

Heart Condition

Allergy

Epilepsy

Low Blood Pressure

High Blood Pressure

Photo Authorisation (Can we take photos of your child playing Netta Skills)

NO Photo Authorisation

Diabetes

Ambulance Subscription

Custody Arrangements

ADHD

ADD

Anxiety

Arthritis

Autism

Aspergers

Court Order

Cystic Fibrosis

Diabetes (Type I or II)

Eczema

Sensory Processing Disorder

Other (please specify)

Question Title

6. Emergency Contact Information

Name

Phone Number

Thank you for completing the registration form, our team will be in touch in the next 48hours to provide details of the program and arrange payment