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Youth Wellness Program Application Form
Children Wellness Program 2019
Please note, you can apply for one child only.
OK
1.
1st Parent/Guardian's details
Name
Email Address
*
2.
Your mobile number without the initial zero
(Required.)
3.
2nd Parent/Guardian's details
Name
Email Address
*
4.
Your mobile number without the initial zero
(Required.)
*
5.
Preferred Method of Contact
(Required.)
Phone
Text
Email
Whatsapp
*
6.
Would you like to receive regular updates about the workshop?
(Required.)
Yes
No
*
7.
In case of emergency please contact
(Required.)
Parent/Guardian 1
Parent/ Guardian 2
Other (Name/Relation/Mobile)
8.
Marital status of parents (Optional)
Married
Seperated
Divorced
Windowed
Prefer not to answer
9.
Living arrangements
10.
Child's details
Child's Name
Nickname/Preferred Name
Date of Birth
Age
School Name
Year
*
11.
Child's gender
(Required.)
Male
Female
*
12.
Any medical conditions that facilitator needs to be aware of?
(Required.)
No
If Yes please explain
13.
Any educational challenges that facilitator needs to be aware of?
No
If Yes please explain
*
14.
Allergies or dietary restrictions?
(Required.)
No
If Yes please give details
15.
Please list siblings details (Optional)
Name/s
Age/s
Gender
School or Univesity
Grade
*
16.
I give permission for my child to be photographed during the workshop
(Required.)
Yes
No
*
17.
I give permission for my child's photos to be shared on ACT Center's Instagram Account
(Required.)
Yes
No
*
18.
I give permission for my child photos to be shared on KAUST social media accounts, FB, Instagram, and KAUST Health websites.
(Required.)
No
If Yes please fill in your Instagram name
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