Wenty Youth Registration Form

Holy Trinity Wentworth Falls

A Parent or Guardian needs to complete this form. If you have any questions about this form please speak to Jono or email jono@holytrinityanglican.org.au

Details of Child

First Name *

Last Name *

Date of Birth *

Gender *

School Grade

Current School

Church Attending

Address where child resides

Home Address *

Home City *

Home State *

Home Post Code

For the purposes of communicating with your child (i.e. reminders of events), feel free to include your child's mobile number and email:

Mobile Number

Email Address

Child's Health Information

Emergency Contact

Tip: if parents can't be reached

Emergency Contact Number

Family Doctor

Doctors Phone

Medicare Number

Medicare Reference Number

Medicare Expiry Date

Please list any known allegies

Allergies

Is your child on a special diet, on any medication (not already noted), have a serious illness or disability, have a known behavioural problem or restricted from any activity? (Please note details and include a treatment/care plan if necessary)

Other Medical Information

I authorise the leaders of Wenty Youth to administer one dose of 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 this medication for my child.

Permission to Administer Paracetamol

Are there any access restrictions to your child?

Details of Parent/Guardian

Parent/Guardian Name *

Parent/Guardian email

Parent/Guardian Phone Number *

Parent Guardian Address (if different from child)

Authority for contact/photography

I consent to my child being contacted by the leaders of this program for Wenty Youth purposes via phone, text, Facebook and email.

I consent to my child’s photo or a video being taken in which my child appears, for use within the program and church in general

I consent to photos of my child being posted on the Wenty Youth Facebook page, Instagram and/or the church website.

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

Please Read the Following

My signature below indicates:

My willingness to permit my child to participate fully in Wenty Youth at Holy Trinity Anglican Church, Wentworth Falls on Friday nights from 7-9pm.

That I give my permission, in 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 for and/or order hospitalisation, injection, anaesthetic or surgery for my child as named. 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 of the youth group will treat all the information contained confidentially. This information may be shared with a third party when it concerns medical health or care of the individuals listed. Please dont hesitate to contact us with any queries in relation to this information.