Registration Form

Reality Youth Group

35 Larnach Rd Traralgon

youth@realitychurch.com.au

www.realitychurch.com

Ps Daniel Robinson

0423892257

It will be great to see your child / children join in the activities we have planned. In order for us to provide the best level of care while your child is under our supervision, we require that you fill out and this registration form. This form only needs to be filled out once per family, per annum. The information below will be treated confidentially within our team.

How many youth are you registering

Youth's Full Name (1)

First NameMiddle NameLast Name

Birth Date (1)

MonthDayYear

Youth's Full Name (2)

First NameMiddle NameLast Name

Birth Date (2)

MonthDayYear

Youth's Full Name (3)

First NameMiddle NameLast Name

Birth Date (3)

MonthDayYear

Youth's Full Name (4)

First NameMiddle NameLast Name

Birth Date (4)

MonthDayYear

Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Guardian

First NameLast Name

Guardian Contact number

Please enter a valid phone number.Format: (000) 000-0000.

SAFETY AND CARE

In the case of an emergency, please list the phone numbers where you and another trusted adult may be contacted during the course of the program.

Emergancy Contact

First NameLast Name

Emergancy Contact number

Please enter a valid phone number.Format: (000) 000-0000.

Do you consent to the appropriate use by us of photographs taken at activities thatinclude your child? (For example, inclusion in our newsletter, pinned tonoticeboard or placement on our website)

Your agreement with TurningPoint Reality Church

I am aware, in signing this declaration regarding my child’s participation in this program, that certain elements of the program could be physically and emotionally demanding. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise exposure to known risks, all hazards associated with these activities cannot be foreseen and may be beyond the control of the organisation, its leaders and staff. I understand that if urgent medical attention is needed, that every effort will be made to contact the persons listed on this form. In the event of any emergency where I or my nominated contact people are unavailable:

1. I authorise the leaders to obtain medical advice and/or assistance which they deem necessary.

2. I further authorise qualified practitioners to administer anaesthetic if required.

3. I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary.

4. I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.

5. I confirm that the information contained in this application is true and correct.

6. I agree to inform the leader of any change to these details.