Reality Youth Medical History Form

Reality Youth Medical History Form

2024
PROTECTING YOUR PRIVACY

Protecting your privacy is important to us. The information we seek allows us to manage risk, provide reasonable care and administer your child / young person’s involvement in our program. We are careful to keep your information confidential, stored securely and provide it only to those agents acting on behalf of the church who need it to enable them to perform their agreed activities (e.g. a Team Member providing First Aid). We only ask for information that is necessary for the purposes outlined in this statement. In some circumstances, if you don't provide us with all requested information, your child/young person could miss the opportunity to be involved in our program. If you would like a copy of our Duty of Care Policy please contact:

Office Ph: 0499354733 Email: youth@realitychurch.com.au
Youth's Full Name

First NameLast Name
Birth Date

MonthDayYear
Date
Their gender?
Guardians's Full Name

First NameLast Name
Guardian Contact Number
Format: 0.
Email Address
example@example.com
Emergancy Contact's Full Name

First NameLast Name
Emergancy Contact's Number
Format: (+61) 000-0000.
Are they taking any medication?
Please list them.
Do they have any known allergies?
Please list them.
MEDICAL CONSENT:

By signing this Medical Information Form you understand / agree that:

·         Team Leaders for this program have your consent to take whatever action necessary to ensure the safety and wellbeing of the group or individual participants under their care (this includes your child).

·         If your child becomes ill or is injured and you cannot or your nominated alternative emergency contact person(s) cannot be contacted, Team Leaders may obtain on your behalf whatever medical treatment is deemed necessary. You also agree to pay for such medical expenses.

·         If you fail or neglect to provide sufficient and current information in writing to enable the proper treatment of your child, no liability will be accepted for any injury or illness, which your child may suffer as a result.

·         Your child’s own doctor may be contacted in the case of any emergency.

·         An ambulance may be called in the case of an emergency.

·         Should any of your child’s medical information change you will inform us as soon as possible.
Signature
Date of Signature

MonthDayYear
Date
Should be Empty: