Stem Club Holiday Program Registration Form

Childs First Name: *

Childs Surname: *

Childs Date of Birth: *

Address: *

Parent / Guardian Name: *

Parent / Guardian Contact Number: *

Parent / Guardian Email Address: *

Does your child have any dietary requirements: *

Does your child have any medical conditions: *

Next of Kin: *

Next of Kin contact Number: *

Does your child have a laptop they can bring: * Yes No

Does your child have an email address they can use for the program: * Yes No