Break Away Holiday Registration Form

Break Away Holiday Programme - Registration

Please note that numbers are limited so register your interest now. 

To register for the Break Away Holiday Programme, please complete the form below and we will be in touch soon to confirm your registration. Alternatively, come and visit us at 250 Pages Road to complete the form manually. 

Parent-Caregiver Details
The following section provides us with important caregiver information. Please ensure details of any medical requirements for your child/children are included .
Parent-Caregiver Name *
Parent-Caregiver Name
Include home, work and/or cell number
Number, Street, Suburb, City
Allergies/asthma/serious illness/injuries or special needs/ dietary requirements or issues for your child/children:
Description of any current medications and instructions for administering to your child/children if required.
Please add details of child/children attending programme below
Young Persons Full Name *
Young Persons Full Name
(Age in years only please)
Data of Birth of the young person
Young Persons Full Name
Young Persons Full Name
(Age in years only please)
Attendance Details
Please check all weeks that your child/children will be attending
Dates of Attendance
Check as appropriate
I give permission for my child/children to be photographed during the Holiday Programme activities. Please note that if you give permission for your child to be photographed, these photographs may be used for reporting purposes; advertising and promotional material. Be assured that this will only occur after Te Runanga o Nga Maata Waka’s executive management have given final approval for any such photos to be used in this way.
Person/s not authorised to collect your child or special instructions regarding collection and access to your child/children:
***If you have additional children you would like to enrol, please add their name, gender and date of birth below***
How did you find out about the Break Away programme?
This information helps us understand the best ways of promoting this programme.
Acknowledgments *
IMPORTANT: To maintain the integrity of the service and the privacy of all enrolled on the programme, mobile phones, cameras or other hand held electronic devices by particpants is NOT permitted. If you require your child to have access to a mobile phone, these should be handed in tot he programme co-ordinator at the beginning of each day and these will be returned to your child at the end of each day.
NOTE: All children must bring lunch and a drink bottle every day.

Privacy act: The information that you have supplied is necessary for the safe and effective operation of the Break Away Holiday Programme. All personal information will be kept confidential. You are welcome to review information pertaining to your child’s enrolment at any time.

IMPORTANT: Please ensure you have read and understood the Acknowledgement at the end of the form above. We must emphasise that any use of hand held electronic devices by children on the programme (this includes cell phones) will NOT be permitted. If it is important that your child has access to a cell phone,  they can be stored safely at the beginning of each day and returned to your child at the end of it. 

Should any of the above details change, it is essential the BREAKAWAY Supervisors are made aware of these changes.


* Fields marked with an asterisk must be filled in to complete the registration process.