BAC Kids / Youth Registration Form

This form is intended to assist leaders in case of any medical emergency during the course of participation in any children's ministry activity.

Your name *

Last name

Email address *

Participant's Details

Participant's Full Name *

Birthdate *

Grade *

Address *

Country

Address line 1

Apt/unit/box (optional)

City

State

Postal code

What program is your child involved in? *

Parent / Guardian Details

Full Name *

Phone number *

Phone type

Email *

Check this box if address is different to the participant you are registering

Emergency Contact

Check this box if the emergency contact is different from Parent / Guardian

Permissions

I consent to my child's participation in the activities I have received notification of. I will encourage my child to participate and co-operate with the leaders and other participants. *

Photography Permission *

Do you give permission to have your child photographed or have footage taken during your child's activities and are willing for your child to be so filmed in appropriate settings? Are you also willing for these photos and footage to be used to promote the ministry in a way that does not identify their name or details?

Healthcare Contact Details

Name of Family Doctor *

Doctor's Phone Number *

Medicare Number: *

Health Care Card Number (if applicable):

Private Health Insurance Fund (if applicable):

Medical Information

Does the participant suffer from any of the following:

Diabetes

Asthma

Migraines

Heart Condition

Epilepsy

ADHD

Other

Does the participant have any known allergies (including drug or food allergies)? *

Has the participant had any recent illness or surgery? *

Will the participant have any medication on them during the relevant program? *

Any other comments that are relevant to your child's engagement in the program

Signatures

Checking this box is to be taken as my digital signature that I have read and understood this form and submit it accordingly. *

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Berwick Anglican Church
info@berwickanglicanchurch.org.au
0397071105

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