Parent Information & Consent Form

Parent Information & Consent Form

School Holiday Program Form
School Holiday*

Term 1Term 2Term 3Term 4
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*

MumDadGuardianOther
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.
Secondary Phone Number
Please enter a valid phone number.
Emergency Contact [Other than Parent/Guardian]
Name*

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.
Health & Medical Information
Does your child have any allergies? (e.g. food, medication, environmental) *

YesNo
Please Specify
Does your child take any regular medication?*

YesNo
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?*

YesNo
Do you give permission for first aid to be administered if required?*

YesNo
Do you consent to your child being photographed for program promotion?*

YesNo
Does your child require a support person (e.g., for additional needs)? *

YesNo
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.*

AgreeDo Not Agree
Parent/Guardian Declaration *

Powered by Jotform SignClear
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