Stomp Out The Ants Enrolment Form

Student's Surname

First Name

Additional student(s) from the same family
Please supply the name of other students who will be attending

Male/Female
Please select the sex of the student

Year Level
Please select the year level of the student

Date of Birth
Please provide the student's birth date

School
Please provide the name of the student's school

Mother's Name

Father's name

Address

Suburb

Postcode

Telephone
Please provide a phone number so you can be contacted

Work Telephone
Please provide a phone number so you can be contacted

Mobile Telephone
Please provide a phone number so you can be contacted

Doctor's Name
Referring doctor's name

Doctor's Provider Number
This generally contains numbers and one or two letters at the end. It is often printed under their signature (or ring the clinic).

Date of Mental Health Care Plan
The date that your doctor completed the 2710 or 2702 for your child.

Doctor's Phone Number

Email Address
Please fill in a valid email address

Receive newsletters (around 4 - 6 per year)

Preferred Program
Select ALL days that your child could attend (sessions are 1.0 hours). Hold the CRTL button for multiple selections

or Reset