Kids’ Club & Junior Youth Registration Form – Eastern Districts Alliance Church

zKids' Club and Junior Youth Registration

To be completed by parent/guardian wishing to register their child/ren for Kids Club or Junior Youth. Cost is $2/week and covers admission, supper and activities. Eftpos is available.

Parent/Guardian Details

Parent/Guardian Name *

First

Last

Phone *

E-mail *

Relationship to Participant *

Alternative Contact (Guardian, Parent etc.) *

First

Last

Please list someone different to the Parent/Guardian above.

Phone *

Relationship to Participant *

I wish to discuss transport assistance to get my child/ren to or from Kids' Club *

Please note, transport assistance is only provided where a caregiver is for some reason unable to fulfil this parenting commitment.

Family Details

Family Address *

Address Line 1

City

State / Province / Region

Postal Code

Private Health Care Provider (if held)

Private Health Policy No. (if relevant)

Participant 1 Details

Name *

First

Last

Date of Birth *

Gender *

Medicare Number

Medical Impairments, allergies or medications

Please include severity of allergy/medical condition and include treatment.

Participant Two Details

Name

First

Last

Date of Birth

Gender

Medicare Number

Medical Impairments, allergies or medications

Please include severity of allergy/medical condition and include treatment.

Participant Three Details

Name

First

Last

Date of Birth

Gender

Medicare Number

Medical Impairments, allergies or medications

Please include severity of allergy/medical condition and include treatment.

Still More?

Additional Participants

List name, date of birth, gender, medicare no. & allergies for each.

Agreement

To be completed by Parent/Guardian or Participants 18+ years old

I consent to appropriate use by EDAC of photographs or videos that include my child/ren. *

Eg. inclusion on our Facebook page, website or a flyer.

I accept EDAC's Privacy Policy *

Field to be completed only by Guardian or Participant 18+ years old. To view our Privacy Policy, please visit the 'About Us' section of our website.

Any additional comments/info:

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