PARENT/GUARDIAN 1
Title
Full Name: First
Last
Phone no
Email Address
example@example.com
PARENT/GUARDIAN 2
Title
Full Name: First
Last
Phone no
Email Address
example@example.com
CHILD 1
Full name: First
Last
Address : Street/Suburb/Postcode
Date of Birth
/
Month
/
Day
Year
Date
School Grade
EMERGENCY CONTACT
(other than parent)
Full name: First
Last
Phone no
Relationship to Child
MEDICAL DETAILS
Allergies: List All allergies your child suffers from
Does your child have an Epipen for allergies?
Yes
No
CONDITIONS / SPECIAL NEEDS
List other medical conditions/special needs here ie. Anaphylaxis, ADHD etc.
Does your child have a medical plan?
Yes
No
If yes, please provide details of your child's medical plan.
OTHER
Are there any person(s) NOT permitted to contact or collect your child/ren whilst in our care? If yes, who?
Is there anything else we need to know about your child?
CHILD 2
Full name: First
Last
Address : Street/Suburb/Postcode
Date of Birth
/
Month
/
Day
Year
Date
School Grade
EMERGENCY CONTACT
(other than parent)
Full name: First
Last
Phone no
Relationship to Child
MEDICAL DETAILS
Allergies: List All allergies your child suffers from
Does your child have an Epipen for allergies?
Yes
No
CONDITIONS / SPECIAL NEEDS
List other medical conditions/special needs here ie. Anaphylaxis, ADHD etc.
Does your child have a medical plan?
Yes
No
If yes, please provide details of your child's medical plan.
OTHER
Are there any person(s) NOT permitted to contact or collect your child/ren whilst in our care? If yes, who?
Is there anything else we need to know about your child?
CHILD 3
Full name: First
Last
Address : Street/Suburb/Postcode
Date of Birth
/
Month
/
Day
Year
Date
School Grade
EMERGENCY CONTACT
(other than parent)
Full name: First
Last
Phone no
Relationship to Child
MEDICAL DETAILS
Allergies: List All allergies your child suffers from
Does your child have an Epipen for allergies?
Yes
No
CONDITIONS / SPECIAL NEEDS
List other medical conditions/special needs here ie. Anaphylaxis, ADHD etc.
Does your child have a medical plan?
Yes
No
If yes, please provide details of your child's medical plan.
OTHER
Are there any person(s) NOT permitted to contact or collect your child/ren whilst in our care? If yes, who?
Is there anything else we need to know about your child?
PHOTOGRAPHY
Please tick appropriate box
I grant Dubbo Baptist Church the right to take photographs of my child/ren.
I agree that Dubbo Baptist Church may use such photographs of my child/ren for any lawful purpose including for example publicity, illustration and website content.
I DO NOT grant Dubbo Baptist Church the right to take photographs of my child/ren.
Parent/Guardian Name
Signature
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: