Parent/Carer Name *

First Name

Last Name

Parent/Carer Phone Number

Country

(###)

###

####

Student Name *

First Name

Last Name

My child would like to participate in the Term 2, 8 Week Jumpstart Program * *

Yes

No

Cost of Program *

I am aware that the cost of the 8 week Jumpstart program is $84.00 and am prepared to pay this cost prior to the start date of the program, if all goes ahead.

Yes

No