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RUKKEL EDUCARE – REGISTRATION FORM

Fill this form to register your interest in the services provided by RUKKEL EDUCARE. We will follow up shortly after your submission.

Child Information

Child's full name

*

Date of birth

*

Age

*

Gender

*

Current School

*

Please provide the name of the school your child currently attends.

What support are you interested in?

*

Select all the services you are interested in.

What support are you interested in?

After School Care

School Pick Up

Tutoring / Transfer Test Prep

Holiday / Summer Programme

Days Required

*

Days Required

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred Start Date

*

Parent/Guardian Information

Parent/Guardian full name

*

Relationship to child

*

Phone number

*

Email address

*

Address

*

Emergency contact if different from above

Emergency contact phone number

Medical Information

Does your child have any allergies?

*

Does your child have any allergies?

A

Yes

B

No

Does your child have any medical conditions we should know about?

*

Does your child have any medical conditions we should know about?

A

Yes

B

No

Any special instructions or requirements?

Consent and Release

Please check all boxes to provide your consent:

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I am the parent/legal guardian of the child named above.

*

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I give permission for my child to participate in the activity(-ies) described above.

*

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I understand the nature of the activity(-ies) and any associated risks.

*

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I give permission for emergency medical treatment if necessary.

*

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I agree to be responsible for any medical expenses incurred.

*

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I release the organizer from liability for injury or loss during participation.

*

Parent/Guardian signature

*

Draw your signature here

Date

*