St Bart's Kids and Youth Registration

Personal Information (Of Child)

First Name *

Middle Name

Last Name *

Preferred Name

Gender *

Date of Birth *

School Grade (Leave blank if not in school)

Dietary Requirements (leave blank if not applicable)

Parent/Carer Mobile Number (no spaces) *

Parent/Carer Email Address *

Home Address *

Home Address Line 2

Home City *

Home State *

Home Postcode *

Home Country *

Registration Form

Medicare Number (including reference number)

Private Health

Yes

Private Health Fund

Doctor's Name

Doctor's Address

Doctor's Phone (no spaces)

Parent/Guardian #1 Name *

Parent/Guardian #1 Phone (no spaces) *

Parent/Guardian #2 Name

Parent/Guardian #2 Phone (no spaces)

Emergency Contact (other than parent) Name *

Emergency Contact Phone (no spaces) *

Emergency Contact #2 (other than parent) Name

Emergency Contact #2 Phone (no spaces)

Custody Matters

Unauthorised Persons (NOT to collect child)

Medical Information

Please leave these fields blank if they do not apply.

Allergies

Asthma

ADD/ADHD

Autism Spectrum Disorder

Behavioural Issues

Diabetes

Epilepsy

Seizures

Heart Condition

Speech/Language Delays

Toilet Trained

Current Medications

Other

Indemnity

I, for my child acknowledge and agree that the Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers, and contractors will not be liable for any loss or damage to any person or property arising from any act or omission by The Corporation of Synod of the Diocese of Brisbane, its employees, agents, officers, and contractors or any participant in the St Bart’s Kids program whether arising under the law of contracttort or otherwise, and indemnify the said Corporation in relation to any such loss and damage.

I consent to my/my child’s participation in all the activities associated with the program and I hereby authorise and consent to The Corporation of the Synod of the Diocese of Brisbane its employees, agents, officers, and contractors obtaining and administering medical assistance, including first aid, paracetamol, transport, blood transfusion, and/or anaesthetic if required and I agree to indemnify The Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers, and contractors for any cost or liability out of the performance of any medical procedure in relation to such medical assistance.

Further I agree to indemnify The Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers, and contractors for any cost or liability arising from any wilful damage of any property, and in the instance of bad behaviour to either come and collect my child or will be liable for the cost of return transport

Indemnity - Please select activities that your child attends *

Kids Club

CHARGE Youth

St Bart's Kids on Sundays (Parent’s Room, Crèche, Preschool, Sunday School)

mainly music

Date of Indemnity *

Type your name below to state you agree to the above indemnity and that all details provided on this form are accurate at time of completion.

Parent/Carer Name *

Photo Permission

During the selected Children’s Ministry activity/activities, St Bart’s, Toowoomba may be taking photographs and video footage to use to promote future parish events, do you give permission for St Bart’s, Toowoomba to use photographs and video footage that may involve your son or daughter in such promotions (include Parish website, Facebook Page, Videos ect.)

Photo Permission *

Date Form Completed *