Kidzmix Enrolment Form

Course Code    
Child's name Date of birth
School Year
Mother's name Father's name
Mother's address
Father's address
Mother's email
Father's email
Mother's mobile Father's mobile
Mother's home phone Father's home phone
Please tick any of the following conditions with which your child has been diagnosed:
 Developmental delay
 Speech or language disorder
 Depression
 Allergies
 Attentional Deficit Disorder – ADHD or ADD 		 Dyspraxia
 Dyslexia
 Anxiety
 Asthma
Other
Name of medication child takes prescribed by a doctor
Are there any health conditions that would impact on your child’s participation?
 My child will be attending the orientation session
 Mother will be attending the orientation session
 Father will be attending the orientation session
Total family members attending the orientation session

Your Message

This complimentary Kidzmix e-newsletter (quarterly) contains information regarding children’s social and emotional competence and general mental health issues.

Parent Behaviour Agreement :

 I agree to the conditions regarding the Behaviour policy of the Kidzmix Program and acknowledge that if my child’s behaviour is disruptive to the group process or learning of other participants, then I will be contacted by mobile and my attendance immediately requested. If I am unable to do so, my child’s enrolment will be terminated and no refund of fees is applicable.

Child’s Behaviour Agreement:

 I agree that I will follow the rules of the Kidzmix Program. I understand that if I am not able to co-operate with the group leader then my parents will be telephoned to attend the program with me. If they are unable to do so and I still cannot follow the leader’s rules, then I will have to leave the program.

Consent:

 I consent to my child being included in sections of the Kidzmix Program that are videotaped. The video tapes are to be used by Helen Davidson, Director, Kidzmix Program for educational and training purposes only.

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