Parent Information & Consent Form

Parent Information & Consent Form

School Holiday Program Form
School Holiday
Child's Details
Name

First NameLast Name
Date of Birth

MonthDayYear
School / Year Level:
Parents / Guardian Details

Primary Contact
Name

First NameLast Name
Relationship To Child

Other
Address

Street Address

Street Address Line 2

SuburbState / Province

Postal / Zip Code
Email
example@example.com
Primary phone Number
Please enter a valid phone number.Format: (+61) 000-000-000.
Secondary Phone Number
Please enter a valid phone number.Format: (+61) 000-000-000.
Emergency Contact [Other than Parent/Guardian]
Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (+61) 000-000-000.
Health & Medical Information
Does your child have any allergies? (e.g. food, medication, environmental)
Please Specify
Does your child take any regular medication?
Please Specify
Any other medical conditions or additional needs we should be aware of?
Doctor’s Name & Contact:
Permissions, Safety & Support Needs
Is your child comfortable being left in the care of staff/volunteers?
Do you give permission for first aid to be administered if required?
Do you consent to your child being photographed for program promotion?
Does your child require a support person (e.g., for additional needs)?
If yes, please provide details:
Drop Off/Pick Up
Drop Off/Pick Up
Are there any specific instructions for drop-off/pick-up?
Authorised Pick-Up
Please list the names of people (other than parents/guardians) authorised to collect your child:
Authorised Pick-Up
Please list the names of people (other than parents/guardians) authorised to collect your child:
Consent
I give permission for my child to participate in the VPCC School Holiday Program.

I understand children must be able to manage independently in a group environment, and that VPCC cannot provide one-on-one specialised support.

I authorise VPCC staff to seek medical treatment for my child in the event of an emergency.

I agree to collect my child immediately if requested due to illness, behaviour, or safety concerns.

I acknowledge it is my responsibility to provide accurate and current contact details, and to advise of any relevant health or support information.
Permission for photographs/video of my child to be taken for promotional purposes.
Parent/Guardian Declaration

I have read and understood the Terms & Conditions of participation.
Date

MonthDayYear
Date
Should be Empty:

Child's Details

Parents / Guardian Details

Emergency Contact [Other than Parent/Guardian]

Health & Medical Information

Permissions, Safety & Support Needs

Drop Off/Pick Up