KBC YTH NEW PERSON FORM • King's Baptist Church

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

School Grade *

School Attending

Tip: if applicable

Home Address *

Suburb *

Postcode *

Child Email Address

Tip: if applicable

Child Mobile Number

Tip: if applicable

First Name *

Tip: 1st Parent/Guardian

Last Name *

Gender *

Relationship to child

Email Address *

Mobile Number *

First Name *

Tip: 2nd parent/guardian

Last Name *

Gender *

Relationship to Child

Email Address *

Tip: Must be different from one above

Mobile Number *

Tip: Must be different from one above

Medical Intervention *

Tip: Do you give permission for medical intervention (including ambulance services) in the case of an emergency and you are not able to be contacted immediately?

Ambulance Cover *

Private medical benefits fund

Tip: if applicable

Medicare Number *

Regular doctor's name and phone number

Has your child had a tetanus immunisation?

Health Concerns *

Tip: Are there any conditions which King's Baptist Church Inc. should be aware of regarding the health and well being for your child eg. Asthma. allergies (food, drugs/medicine), convulsive seizures, diabetic?

Medications

Promotional Material *

Tip: Do you give permission for your child's photo to be taken and used for promotion, either in printed material (on display or newsletter) or online (church website, facebook page)?

Transport *

Tip: Do you give permission for your child to be driven in a vehicle by King's Baptist Youth Leaders, who hold a Provisional or Full License?

Communication *

Tip: Do you give permission for your child to be contacted via text message or social media by King's Baptist Youth Leaders of the same gender?

Consent *

Yes

Tip: I give my child permission to attend King's Baptist Church Youth and understand that every caution will be taken to ensure their welfare. I give permission to first aid trained Leaders to ensure proper treatment for my child and in the event of an emergency. I am aware that all doctor, ambulance and hospital fees incurred in these instances are payable by myself as the consenting parent/caregiver.

Consenting Parent/Caregiver Full Name

Today's Date

Child Personal Information

Family Contact Details

Emergency Contact

Medical Information

Permissions