Sir Peter Blake Marine Education and Recreation Centre 

held from Tuesday, April 30, 2019, to Friday, May 3, 2019, in week 1 of Term 2.

The cost per student is $180. Please pay to the office or via internet banking 03-0418-0145370-00 referencing your child’s surname and MERC.

1045 Beach Rd, Long Bay, North Shore City 0630 

PO Box 35-119, Browns Bay, North Shore City 0753 

Telephone: (09) 473 0714 Residential: (09) 473 0713 Fax. (09) 473 1945 

Email: office@merc.org.nz Website: www.merc.org.nz 

Student Details

Student Name
Age Details
Medical Contact Details
Primary Emergency Contact
Second Emergency Contact

Medical History

Please answer all questions & provide additional details where appropriate
Regular medication?
Does your child require any regular medication?
Does your child have any illness?
Medical Concerns
Does your child have any medical concerns that may affect participation in activities
General Medical
Has your child had a full programme of tetanus injections?
Has your child had flu within the last two weeks?
Has your child had any recent ear problems?
Does your child have physical or intellectual disability?
Does your child have a problem with bed wetting?
Does your child suffer from homesickness?
Is your child allergic to any substances?
Is your child allergic to bee stings?
Does your child have any dietary requirements?
Can your child swim?
Is your child confident in deep water?
I approve of my child attending MERC and they are able to participate in all presented activities.
MERC staff will provide full safety briefings to all participants.