Youth and Kids Registration Form

St Marys and St Clair Anglican Church

A Parent or Guardian must fill out this form. If you have any questions then please speak to Evan (email: evanhmoses@gmail.com)

Child's Details

First Name *

Last Name *

Date of Birth *

Gender *

School Grade

School Attending

Church Attending

Contact Details

Parent/Guardian's Names *

Home Address *

Home City *

Home State

Home Post Code

Parent/Guardian Mobile Number *

Parent/Guardian Email Address *

Emergency Contact Name

Emergency Contact Relation to Child

Emergency Contact Number (different to Parent/Guardian number if possible)

If you would like the leaders of the program to contact your child directly for the purposes of the ministry, then please give their details below

Child's Mobile Number

Child's Email Address

Medical Information

Doctor's Name

Doctor's Number

Medicare Number

Medicare Expiry Date

Allergies/Dietary Requirements

Is your child on any medication, have any serious illness or disability, have a known behavioural issue or is restricted from any activity? If so, please give details

Other Medical Information

I authorise the leaders to administer paracetamol to my child as per the instructions on the medication. I understand that this authority is a guideline for administration of a specific dose, and acknowledge the potential side effects and risk of medication for my child

Administering Paracetamol

Are there any access restrictions to your child?

Authority for Contact/Photography

I consent to my child being contacted by one of the leaders of this program for ministry purposes by phone, email or Facebook

I consent to photos or videos being taken, in which my child appears, for use within the program and church in general

I consent for my child's photo or video to be taken and used for display in the church hall and for other advertising purposes

I consent for photos or videos of my child to be posted on the ministry's Facebook page and/or the church website

Please read the following:

My signature below indicates:

My willingness to permit my child to participate fully in the youth and kids ministries of St Marys and St Clair Anglican Church
That all the above information is correct and complete at the time of signing
That I give permission for my child to attend planned activities at Bennett Park (across the road from the St Marys church property) under full leadership supervision and only during youth group and daylight hours
That I give my permission, the case of a medical emergency, to the doctor chosen (either by the church authorities or other persons supervising or administering the activities) to secure proper treatment and/or hospitalisation, injection, anaesthetic or surgery for my child. I understand that every effort will be made to contact me prior to instituting such procedures

Selecting "Yes" below certifies acceptance of all these conditions

Permission Given *

Date Registration Form Completed *

The leadership team will treat all the information collected confidentially. This information may be shared with a third party when it concerns the medical health or care of the individuals listed.