Family Registration Form 2025
Welcome to Phillip Island Baptist Church (PIBC). In order for us to provide the highest level of safety and care we require that you complete and return this registration form for attendance at our ministries, programs and events.
Parent/Guardian (1)
*
First Name
Last Name
Contact Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State
Post Code
Postal Address
Postal Address
Postal Address Line 2
City
State
Post Code
Parent/Guardian (2)
First Name
Last Name
Contact Phone
Please enter a valid phone number.
Email
example@example.com
Back
Next
Child 1
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Female
Male
Other
Please detail any preferences for Ethnicity, Culture, Gender, Name, Pronouns or other Identifications
Child 2
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Female
Male
Other
Please detail any preferences for Ethnicity, Culture, Gender, Name, Pronouns or other Identifications
Child 3
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Female
Male
Other
Please detail any preferences for Ethnicity, Culture, Gender, Name, Pronouns or other Identifications
Child 4
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Female
Male
Other
Please detail any preferences for Ethnicity, Culture, Gender, Name, Pronouns or other Identifications
Back
Next
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1 Phone
*
Please enter a valid phone number.
Emergency Contact 2
First Name
Last Name
Emergency Contact 2 Phone
Please enter a valid phone number.
Any other adults that have permission to pick children listed above.
Name and Phone Number
Back
Next
There may be occasions when it is necessary for a leader or helper in our team to transport Youth or Children between premises for a program, or to walk to nearby facilities for special care needs, or emergencies. I give my permission for my Youth & or Child/ren, to be transported by PIBC approved leaders and support drivers who are Licensed, and on the condition that I am advised.
*
Please Select
Yes
No
Custody Arrangements and Court Orders
If there are any custody arrangements or court orders that PIBC team should be aware of, please detail them here or upload below.
Custody Arrangements and Court Orders
Browse Files
Drag and drop files here
Choose a file
If there are any custody arrangements or court orders that PIBC team should be aware of, please upload documents here.
Cancel
of
Allergies and Medical Information
Please list include CHILD'S NAME and any allergies, dietary restrictions, medical or behavioural information that PIBC needs to be aware of.
Medicare Number
*
Medicare Expiry
*
-
Day
-
Month
Year
Date
Private Health Insurance
Ambulance Membership Number
Do you allow Paracetamol to be administered to your child/ren if required?
*
Please Select
Yes
No
Approximate Date of last tetanus immunisation
*
-
Day
-
Month
Year
Date
Family GP
Back
Next
Media and Advertising - do you permit photo images/video to be taken of your child/ren for the use of INTERNAL promotions such as wall posters, highlight videos and slideshow presentations?
*
Please Select
Yes
No
Media and Advertising - do you permit photo images/video to be taken of your child/ren for the use of EXTERNAL promotions such as newsletters, church website, social media, flyers and YouTube.
*
Please Select
Yes
No
Please note: PIBC will not tag children or their family members in any posts uploaded to social media
Privacy Policy
In accordance with the National Privacy Principles and Privacy Act, any information contained in this directory will be used only for the ministry of this church and activities related to this church.Information will not be released to any organisation outside of this church without prior consent.
Use of Personal Details
PIBC will send relevant information and advertising via email and/or text message related to the ministries and programs that your Youth or Children are a part of to the primary contact person on this form ONLY.
Exemption of Liability
I authorise the leader/s in charge of the above noted Island Youth or Island Kids ministries, to communicate, where applicable and practical with me, to arrange for my Youth or Child to receive such medical or surgical treatment as the leader/s may deem necessary at any time whilst under the care of Phillip Island Baptist Church.I further authorise the use of Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment.I appreciate that every care will be taken by the leaders and those connected to Phillip Island Baptist Church cannot be held responsible for personal injury, loss or theft of property affecting my Youth or Child/ren.
Our Commitment to Child Safety
Phillip Island Baptist Church is committed to protecting the safety of all people within its ministries, services, and events. Our Policy has been developed to uphold this commitment to safeguard people, and to adhere to the national and local legislation. To view our Safe Churches policy please visit our Website:https://www.islandbaptist.org.au
Name - Type your full name here as your digital signature.
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
Submit
Should be Empty: