Reserve a PlacePlease enter your details to reserver a place on a program. We will confirm as soon as possible. Participant's Name * First Name Last Name Date of Birth * MM DD YYYY Program * Tamariki After School Program Next Tamariki Holiday Program Rangitahi Thursday Night Basketball Next Rangitahi Holiday Program TruMotion Under 12 Thursday Afternoon Basketball Caregivers Name * First Name Last Name Caregivers Email * Caregivers Phone * (###) ### #### Health Information Do you require medication? * Yes No Details Do you, or have you had any illness such as diabetes, heart problems, asthma, epilepsy etc? * Yes No Details Do you suffer from any allergies? * Yes No Details Is there any information we should know to ensure your physical and emotional safety? * Any behaviour or emotional issues, disability, cultural practices etc Yes No Details Have you had any illnesses within the last two weeks? * Yes No Details Do you have any special dietary requirements? * Yes No Details Date of last tetanus MM DD YYYY Any other information we should know about? Assistance you will need? Consent My daughter/son/cared-for child may be given the following medication Panadol Antihistamine (for insect stings/bites, hay fever, and other mild allergic reactions) Adrenalin (only in case of extreme anaphylactic reaction) I give permission for my daughter/son/cared-for child to have photo/video taken for our website or Facebook page * Yes No By checking this I agree to give consent for my daughter/son/cared-for child to be involved in the above activity and agree to them receiving emergency first aid or medical treatment if considered necessary by a staff member trained in First Aid. * Yes No Thank you for your registration. We will be in contact soon to confirm your registration.