Youth Alpha Registration
Participant's Details
Child's Name:
*
First Name
Last Name
Child's date of birth (if aged 18 must still be attending school)
*
-
Month
-
Day
Year
Date
Child's year level
*
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Workforce (under 18)
Child's Gender
Male
Female
Does your child have any allergies?
*
Yes
No
If yes, please specify:
Does your child have any medical conditions that we should know about?
*
Yes
No
If yes, please specify
Does your child have any dietary requirements?
*
Yes
No
If yes, please specify
Are there any court or other legal orders related to your child?
Parent/Guardian Details
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2nd Parent/Guardian Name
First Name
Last Name
Phone number
Email
example@example.com
Emergency Contact
Emergency Contact
*
First Name
Last Name
Relation to Child
*
Not already listed
Phone number
*
Permissions
Medical Consent
*
I authorise the leader in charge of Youth Alpha to arrange for my child to receive any first aid or medical treatment as the leader may deem necessary. I also authorise the use of an Ambulance in case of medical emergency. I accept responsibility for payment of all expenses associated with such treatment.
I consent to photos of my child to displayed during the Youth Alpha program
*
Yes
No
Do you authorise your child to sign themselves into the event?
*
Yes
No
Do you authorise your child to sign themselves out of the event?
*
Yes
No
Additional Contacts
Please list any people you would like to authorise to (in addition to the Parent/Guardian) to sign your child in/out of the event
Name:
First and last name
Number:
Phone number
Name
First and last name
Number
Phone number
Attendance Consent
*
As the Parent / Guardian, I give permission for my child to attend Youth Alpha run by Korumburra Baptist Church, help at Chairo Christian School Leongatha Campus, 101 Horn St, Leongatha VIC 3953
Signature
Submit
Should be Empty: