Jungle Adventure Rego Form

JUNGLE ADVENTURE - Kids Holiday Club rego form

Childrens details (all details are for child, parents details in the next section)

Last Name

First Name

Gender

Date of Birth

Mobile Number

Email Address

School Grade

Mailing Address

Does your child have any allergies?

Tip: Please provide details and allergy action plan if applicable

Does your child have any special needs?

Tip: If yes please provide any relevant information

Does your child have any behavioural issues?

Medications/ Special diets/ activity restrictions?

Is there anyone legally restricted from seeing your child?

Medicare number

Card reference number

Photos and videos of my child may be displayed publicly (online and in print)

Parent and emergency contacts

Please provide one primary contact and 2 other contacts incase of emergency

Primary contact

Description

Name *

Relationship to child?

Phone number *

email address

Additional contact

Name *

Relationship to child

Phone number *

email address

Additional contact

Name

Relationship to child

Phone number

Permission and authorisation

My signature below indicates:

My willingness to permit my child to participate fully in "JUNGLE ADVENTURE" Kids Holiday Club at Robertson Anglican Church.
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.

Signed *

Date *

Privacy Declaration
Robertson Anglican Church is exempt from the requirements of the Privacy Act 1988 (Cth) as it is a small business. However, we seek to deal carefully with the personal information we collect and to do so in a manner consistent with your reasonable expectations.

The personal information in this form will be made available to
(a) the leaders involved in the running of the activities in which my child participates, ministry staff, safe ministry representative, and
(b) medical and emergency services if considered necessary.

Payments

The cost for the day is $25 per child which includes all activites, morning tea, lunch, and afternoon tea.

Payments can be made via direct debit into the church account - please state JUNGLE in the description.

Cash and eftpos* payments are aviable on the day

*eftpos payments will incure a small surcharge

I will pay