REGISTRATION & CONSENT FORM FOR MUM & ME TIME
In line with our commitment to safe ministry practices, the information collected in this form will be used by appointed program leaders and stored securely by Southern Cross Presbyterian Church.
REGISTRATION
Parent/carer details
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number (mobile preferred).
Do you consent to your name and phone number being included on the term roster?
*
Yes
No
Date of Birth
*
.
Day
.
Month
Year
Date
What brought you to Mum & Me Time?
*
Social time for child/ren
Social time for myself
Support as a mum
Other
CHILDREN
Child 1
*
First Name
Last Name
Date of Birth
*
.
Day
.
Month
Year
Date
Gender
*
Please provide any information regarding illness, allergies and/or special needs for this child.
*
Child 2
First Name
Last Name
Date of Birth (child 2)
.
Day
.
Month
Year
Date
Gender (child 2)
Please provide any information regarding illness, allergies and/or special needs for this child (child 2).
Child 3
First Name
Last Name
Date of Birth (child 3)
.
Day
.
Month
Year
Date
Gender (child 3)
Please provide any information regarding illness, allergies and/or special needs for this child (child 3).
Child 4
First Name
Last Name
Date of Birth (child 4)
.
Day
.
Month
Year
Date
Gender (child 4)
Please provide any information regarding illness, allergies and/or special needs for this child (child 4).
EMERGENCY CONTACT
Emergency contact (other than parent/carer listed above)
*
First Name
Last Name
Relationship to family
*
Phone Number
*
Please enter a valid phone number (mobile preferred).
By signing this form, I authorise the leaders of this program, in the event of an emergency, to obtain at my expense any medical, ambulance or similar services considered necessary for myself or my child/ren.
*
Clear
Date
*
.
Day
.
Month
Year
Date
CONSENT FOR IMAGES
At Southern Cross Presbyterian Church (SCPC), we use photos and videos taken at our various activities and events to promote and celebrate our ministries. ‘Images’ (photographs and/or video recordings) may be used both internally and externally for publications and materials including (but not limited to) church family news, advertising materials, church family publications, church website and other online platforms. All images will be stored securely and used only as stated.
*
I understand
If circumstances change, you can inform us of your wish to withdraw this consent. We will then seek to remove the image where it appears in digital formats but may not be able to retract printed material. Individuals may also request specific images be removed.
*
I understand.
I give permission for images containing my child to be used both internally and externally for SCPC publications and materials including (but not limited to) church family news, advertising materials, church family publications, church website and other online platforms.
*
Yes, I give permission.
No, I do not give permission
The consent given for 'images' will operate until I expressly revoke it.
*
I understand.
PRIVACY
Personal information collected is used only for purposes relating to the spiritual, pastoral, social, educational, administrative, legal and historical functions of the Church subject to the Church‘s Privacy Policy in accordance with the Privacy Amendment (Private Sector) Act 2000. Your acceptance of this written advice will be regarded as your consent to collect and so use the information as described. If you do not consent please advise immediately. A copy of the Church‘s Privacy Policy is available on the PCNSW website or upon request. Personal information will not be used for any other purpose without first obtaining your consent. Please tick all before continuing.
*
I agree that the information contained on this Child Registration Form is true and correct.
I agree that I will ensure that any changes to this information are advised in writing as soon as possible.
I understand the consent given in this form will operate until I expressly revoke it.
SIGNATURE
Please make sure to sign in one of the signature fields. Failure to do so will require you to complete the form again.
Name
*
First Name
Last Name
If using a phone/tablet please sign here:
Clear
If using a desktop computer please upload signature here:
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