CHILD ENROLMENT AND CONTACT DETAILS FORM

CHILD ENROLMENT AND CONTACT DETAILS FORM
Welcome to Westgate Vineyard Church.

Please complete the following information form about your child including contact details and medical information. This form will be kept on file, in a secure cabinet at Westgate Vineyard Church.
Name of Child
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Age
Address
Does the child have any siblings:

YesNo
If yes, who are they and what are their ages
Does the child have any siblings:

YesNo
If yes please provide details
Does your child have any particular interests/hobbies (please include your child when completing this information)
Parent/Guardian 1
Relationship
Mobile Number
Format: (0000) 000000.
Address
Relationship
Parent/Guardian 2
Mobile Number
Format: (0000) 000000.
Address
Are there any other significant adults involved in your child's life that it might be important we know about?

YesNo
Please provide details
Emergency Contact 1
Full Name
Relationship to child
Contact number
Emergency Contact 2
Full Name
Relationship to child
Contact number
Court Orders
Are there any court/custody orders WVC should be aware of

YesNo
If yes, please describe ( a copy may be required to be kept on the child's file)
Medical Infomation
Medical Insurer
Medicare number
Medicare expiry
Reference number
Usual Doctor
Address
Phone

Area CodePhone Number
Medical History

Please provide further details/information
Heart trouble?

YesNo
Further details information:
Respiratory Problems?

YesNo
Further details information:
Asthma

YesNo
Severity:

LowMediumHighExtreme
Would hospitalisation be required?

YesNo
Asthma (resect hospitalisation)

YesNo
If so, what date:
Allergies

YesNo
Allergies

BeesWaspsAnimalsPlantsFoodDrugsOther
Give details:
Severity:

LowMediumHighExtreme
Would hospitalisation be required?

YesNo
Does your child suffer from anaphylaxis?

YesNo
If yes, please provide an Anaphylaxis Plan
Do they have an epipen?

YesNo
Further details information:
Blood pressure problems?

YesNo
Further details information:
Diabetes

YesNo
Have you discussed their needs and treatment with the Leader?

YesNo
Further details information:
Phobias

YesNo
Further details information:
Do they have an Epolepsy?

YesNo
Have you discussed their needs and treatment with the Leader?

YesNo
Further details information:
Sleep Walking?

YesNo
Further details information:
Bed Wetting?

YesNo
Further details information:
Operations?

YesNo
Further details information:
Further details information:
Recent illness?

YesNo
Further details information:
Tetanus up-to-date?

YesNo
Last date?
Further details information:
Can pain killers be provided? (Panadol/Aspirin?Codeine/etc)?

YesNo
Further details information:
Current Medications:

YesNo
Further details information:
Swimmer?

YesNo
Competent distant:
Dietary Requirements:

YesNo
Further details information:
Any other information:
Medical Authorisations
I understand that WVC will endeavour to provide a safe environment for my child at all times.
I/We Parent/caregiver name* being the parents/guardians of the above child agree that in the event of an injury and if medical attention is needed, I authorise the leader to call an ambulance or seek medical advice and I will cover all medical expenses

In the case of personal injury, loss or damage, I, or a third party, will not hold WVC or its employees and volunteers responsible.
Signature of parent/guardian*
Date*

MonthDayYear
Date
I/We name of parent/cargiver*being the parent/guardian of the above child, hereby acknowledge that the above information is true.
I understand that it is my responsibility to inform the WVC Child Safe Leader or the leader of the program/event that my child is involved in of any changes to this information.
Signature of parent/guardian*
Date*

MonthDayYear
Date
Should be Empty:

CHILD ENROLMENT AND CONTACT DETAILS FORM

Court Orders

Medical Infomation

Medical History

Medical Authorisations