Dubbo Uniting Church Advent Workshops Permission and Medical Form

Dubbo Uniting Church

Advent Workshops 2024
Name of child*
Preferred Name
Family Names*
Address*
Phone*
Email*
example@example.com
Alternate emergency contacts: (at least one required)
Name*
Relationship to child*
Phone*
Name
Relationship to child
Phone
Please give details of a any persons not permitted to contact or collect your children while in the care of the abovenamed group and b any Court order related to such
I consent to my child becoming a member of the Dubbo Uniting Church Advent Workshop. Iwill encourage my child to attend, participate and to cooperate with the leaders and other children. I authorise the leaders in charge of the abovementioned group where it is impracticable to communicate with me, to arrange for my child to receive such medical treatment as the leaders may deem necessary at any time during the activities of the Advent Workshop. I further authorise the use of Ambulance if in the leader's judgment it is necessary. I accept responsibility for payment of all expenses associated with such treatment. Iappreciate that every care will be taken by the leaders of the abovementioned group and that the leaders and those connected with that group cannot be held responsible for personal injury, loss or theft of property affecting my child.
Do you permission for your child to be administered Paracetamol for minor ailments at the discretion of the First Aid leaders?
I understand that photos may be used by the Uniting Church for promotional purposes.
Signature of parent/guardian

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Name
Date

MonthDayYear
Date
Please complete the following medical information.
Please tick if your child suffers from any of the following:

Heart conditionBlackoutsAsthmaMigraines
Is your child presently taking medication?

YesNo
If yes please state the name of the medication dosage etc
Is your child allergic or intolerant to Penicillin?

YesNo
Is your child allergic to certain foods?

NutsGlutenEggsOther
Medicare No*
Medical Hospital Fund
Contribution No
Name of family doctor
Family Doctor Phone
Name of Dentist
Dentist Phone
Please list any physical or special needs eg dietary requirements food allergies
The leadership team of the event will treat the information contained confidentially. This information may be shared with a third party when it concerns medical health or care of the individuals listed.

PRIVACY POLICY - IN SHORT

Dubbo Uniting Church collects personal and/or sensitive information to assist in providing spiritual, pastoral, social, educational and administrative functions. The Dubbo Uniting Church may contact you from time to time to let you know about items that may be of interest. Ifyou wish to access your information or have any queries please contact the Privacy Officer by one of the following: Mail: Privacy Officer, Dubbo Uniting Church, PO Box 1003 Dubbo NSW 2830 Phone: 02 6885 4200 Email: dubbouca@outlook.com
DUBBO UNITING CHURCH

64-66 Church Street Dubbo Ph: 6885 4200. E: dubbouca@outlook.com. W: dubbo.uca.org.au
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DUBBO UNITING CHURCH