Registration | Koorie Homework Club

Koorie Homework Club Registration Form

Student Details

First Name *

Last Name *

If Self Described

Date of Birth *

Grade *

School *

Parent/Guardian Details

First Name *

Last Name *

Email Address

Please send me important news and updates regarding Koorie Homework Club

Home Address

Address 1 *

City *

ZIP / Postal Code *

State / Province *

Country *

Parent/Guardian Phone Number *

Alternative Phone Number

Secondary Contact

Relationship to student

Phone Number

I give permission for my child/children to receive medical treatment in the event of an emergency *

Yes

I give permission for photographs, film, tape and recordings to be taken of my children and for their use in promotional materials. *

Yes

Existing Medical Conditions