Parent / Caregiver & Child Registration Form

Vision

Our Best Generation Yet!

Connecting Hearts & Minds through Families & Communities Learning Together…

Sita Selupe B.Ed, Dip Tchg
Cecily Taufelila B.Ed, Dip Tchg
Joseph Seniloli
Andrew Letiu

Learning
Family
Community
Truth in Love

For registrations or more information about any of our programmes, please contact:

Cecily Taufelila on 09 276 8727 or 021 190 7689

Please view our Privacy Policy at the bottom of the website

Personal Details (Parent / Caregiver)
Which event are you registering for?*
- Hearts and Minds
- Synergy
Family Name*
Given Name(s)*
Preferred First Name*
Preferred Title*
- Ms
- Miss
- Mrs
- Mr
Ethnicity*
Date of Birth*

DD
MM
YYYY
Gender*
- Male
- Female
Personal Details (Children)
Child Details*
For each extra child you wish to add, please click on the [+] button at the end of the row
Family Name Given Name(s) Date of Birth (DD/MM/YYYY) Gender Ethnicity
Contact Details
Address*
Street Address Suburb Town/City Postcode
Home Phone Number*
Mobile Number*
Email Address*
Enter Email Confirm Email
Declaration*
- Yes, I agree
I declare to the best of my knowledge all the information supplied on, and with this registration form is true and complete, I agree to abide by the conditions as described above and I consent to the disclosure of personal information/photos as described above. I also agree and accept responsibility for ensuring my child’s safety at all times during attendance of Rise UP Trust Programmes.
Your Name*
Signature*
Use your mouse, stylus or finger to sign

Family Name	Given Name(s)	Date of Birth (DD/MM/YYYY)	Gender	Ethnicity