ICONZ Registration

Please register my son for *

ICONZ Adventure – for ages 8 - 10 (years 4-6)

ICONZ Junior Delta – for ages 11-15 (years 7-11)

Registration Fees (please choose one)

Per Term (must be paid by first week of term)

	Quantity	Price	Total
ICONZ Term Registration Fee		$35.00	$

Full Year

	Quantity	Price	Total
ICONZ Full Year Registration Fee		$140.00	$

T-Shirt

	Quantity	Price	Total
ICONZ T-Shirt		$25.00	$

Cap

	Quantity	Price	Total
ICONZ Cap		$20.00	$

Child's Details

Child's Name *

First name

Last name

Date of Birth

Year at school *

Which school of attendance *

Allergies/Medical/Dietary Requirements

Parent/Guardian Details

Name *

Email *

Home phone

Cell phone *

Address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Emergency Contact Person & Phone No. (other than parent) *

Photo & Privacy consent - I consent

I understand that by filling out this form my information may be kept on file by Hope Presbyterian (and it's associated groups) to use for administrative purposes. I understand that photos from this event that may include pictures of me/others may be used by Hope Presbyterian (and it's associated groups) for promotional purposes.

ICONZ Consent *

I give permission for my son to take part in activities within our local community with the Unit Leaders. I understand that if any activities are to be undertaken further afield I will be notified as and when they occur.

Accident Liability *

I understand that while ICONZ leaders will take all responsibility to ensure the safety of my son, they cannot be held liable for consequences resulting from any accidental injury while he is in their care.