Southern Stars Charitable Trust - Helping Kids to be Kids

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Southern Stars Grant-A-Wish

Please complete the form below to submit an application for your child to go into the "Southern Stars Grant-A-Wish" programme.

If you wish to know more without applying, please contact Keith by one of the following methods.

Chief Executive	Keith Slater
Direct Dial	+64 9 361 4530
Email	keith@southernstars.org.nz

Dated
Full name of Parent/Guardian
Full name of Child
Child's Date of Birth
Postal Address
Mobile
Email
Your Child's Wish
Why would your child like this wish granted
Any Special Circumstances

I, the parent/guardian, hereby give permission for my child to participate in "Southern Stars Grant-A-Wish". I agree that the organiser may use my child's name, photograph, likeness, voice and biographical details, or any personal information in conjunction with "Southern Stars Grant-A-Wish" in all media and all formats. I hereby, declare further that there are no known medical conditions preventing my child from participating in the activitiy chosen.

I have read and agree to both the Entry Rules/Criteria and the above statement.