Child 1 *

First Name

Last Name

Additional Child

If applicable

First Name

Last Name

Additional Child

If applicable

First Name

Last Name

Parent/Carer Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

What program are you interested in enrolling your child in?:

Tuesday 8th July (ages 10 - 15 year olds) 11:00am -3:00pm

Tuesday 15th July (ages 10 - 15 year olds) 11:00am -3:00pm

Consent to use photographs and images (optional)

You agree that All Stars for Autism Incorporated may take photographs and video footage of you/your child/your children undertaking activities and use it for the purposes of marketing and promotion of All Stars for Autism Incorporated and its goods or services. This may include printed and digital marketing, including the use of you/your child/your children image on social media platforms.

Yes

No

Consent to treat minor medical ailments *

Do you consent for staff to treat minor ailments (eg. Bandaids)

Yes

No

Exclusion of Liability

This agreement releases All Stars for Autism Inc. from all liability relating to injuries that may occur during All Stars for Autism’s events. By signing this agreement, I agree to absolve All Stars for Autism Inc. from all liability however arising, from injury or damage however caused, arising out of mine or my child’s membership and/or participation in any All Stars for Autism activity.

Yes

No

Privacy Policy *

Do you agree to the All Stars for Autism Privacy Policy here.

Yes

No

Date

MM

DD

YYYY