Out of Uniform Day School Registration

Name

First Last

Name of School

Email

Type of School

Please select one of the following that describes your school:

Primary School
Secondary School
Specialist School

Address

Street Address Address Line 2 City/Suburb State/Territory Postcode

Event Date*

What date is your school participating in Out of School Uniform Day to assist Keeley's Cause fundraising efforts?

How many children attend your school? (Approximately)

Who will be responsible for the deposit of raised funds to Keeley's Cause bank account?

Do you require Keeley’s Cause DL Flyers to bring awareness of what children are raising for ?

Yes
No

Please note :
All funds raised must be deposited to Keeley's Cause
Limited within 7 days of your fundraising event.

Funds are to be deposited to
Keeleys Cause Limited
Bendigo Bank
BSB : 633-000
ACC

Or

By Cheque payable to KEELEYS CAUSE and sent via express
post to

KEELEYS CAUSE
P.O. BOX 169
BALLAN VIC 3342

Please select your preferred payment:*

Do you currently have any children with Autism or an Intellectual Disability at your school?*

Yes
No

If yes, then how many children attend your school with Autism or an Intellectual Disability?

How many of them have an iPad at your school?

Thank you for your time in filling out this form.

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Out of Uniform Day School Registration