Peninsula City Youth (PCY) Registration Form

Registration Form 2026
PCY Attendee's Personal Information
Full Name
D.O.B

DayMonthYear
Date
Year Level
Gender
School
Please upload a photo of this youth person for our Check in system

Cancelof
Do you currently attend a church?
If you are attending a church, please tell us which church you call home.
Your Home Address

Home Address

Street Address Line 2

SuburbState / Province

Postal / Zip Code
Postcode
Parental Communication Consent
I give permission for my child to be added to a closed PCY message group available through the PenCC app. I understand that this group is to encourage and support PCY participants to feel connected to their PCY community.
Email (Youth person's email not parents - please leave blank if they don't have one)
example@example.com
Phone (m) - Youth person, not parent - please leave blank if N/A
Format: 0000-000-000.
Doctor Name
Format: (000) 000-0000.
Doctor Name
Doctor Phone number
Format: (00) 0000-0000.
Medicare Card No
Number/Position on Medicare card
Ambulance No
Health Insurance Provider
Health Insurance No
Date of last tetanus immunisation
Medical/Additional Needs Information

Does this person have any medical conditions or allergies we need to be aware of?

Medical/Allergy Management Action Plan 2026
Medical Condition/Allergy
Causes/Triggers:
Signs and symptoms:
Treatment/Medication:
Is this child/young person able to self-administer treatment?
Please upload any Management plans you have (if applicable):

Cancelof
Is there any additional information that would be helpful for us to know about your child's medical condition/allergy?
Medical/Additional needs brief info (please complete additional needs form for more detailed information)

Does this person have any additional needs it would be helpful for us to know about?

Additional Needs Information 2026
Current diagnosis, medical condition or learning difference:
Triggers, signs and symptoms of tiredness or frustration:
Management of frustration and tiredness:
My child really enjoys the following activities:
My child needs extra help with the following activities:
Please upload any Management plans you have (if applicable):

Cancelof
Is there any additional information that would be helpful for us to know about your child's additional needs?

Is there anything else the leader(s) should know about your child?
Parent/Guardian Details
Parent/Guardian 1 Name

First NameLast Name
Parent/Guardian 1 Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Parent/Guardian 1 Email
example@example.com
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Parent/Guardian 2 Email
example@example.com
Parental Consent to seek medical attention:
If the leader in charge is unable to communicate with me, I authorise the leader in charge to consent to my child travelling in an ambulance and receiving medical or surgical attention if deemed necessary.
Custody Arrangements
Are there any custody arrangements you would like us to be aware of?
If yes, please explain
Parental Permission to take Photographs:
I hereby give permission to the Leaders to take photographs of my child while he/she participates in planned activities. I do so with the knowledge that these photos may be copied and distributed to other attendees as a memory of their involvement. I also give permission to the use of some of these photos in future advertising of Peninsula City Youth activities.
Parent's / Guardian's Signature
Date

DayMonthYear
Date
Peninsula City Church is a Child safe Church. We only collect information where it is necessary to do so to provide a service to you, or where we are required by law to do so. Access to personal information is restricted to support staff. We will not pass any of your personal details to any other organisation.

We seek to accommodate all children/Young people who wish to participate, however, our duty of care in respect to supervision ratios may mean that we are not able to provide adequate support for your child if they require constant attention by a leader to participate in our program(s).
Communication Consent
Should be Empty:

Registration Form 2026

PCY Attendee's Personal Information

Parental Communication Consent

Medical/Allergy Management Action Plan 2026

Additional Needs Information 2026

Parent/Guardian Details