Big Beautiful and Blessed Junior Application

1
First Name* This field is required.
2
Last Name * This field is required.
3
Address
4
City & State
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Postcode* This field is required.
6
Home Ph:
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Participants Mobile No* This field is required.
8
E-mail* This field is required.
9
School Year* This field is required.Those young ladies out of High School are considered our LEADERS
Please Select
Please Select
Grade 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Leader
10
School
11
Gender* This field is required.Positively MY IMAGE is a program for young ladies only at this time. However, we may have opportunities for you son to volunteer in the future if you are interested that opportunity.
Male
Female
12
Date of Birth* This field is required.
13
Parent/Guardian Name* This field is required.
14
Parent Guardian Name* This field is required.
15
Parent Mobile
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Parent email* This field is required.
17
Emergency Contact Name* This field is required.
18
Home Phone* This field is required.
19
Mobile Phone
20
Email
21
Relationship to Participant* This field is required.
22
What is it that you hope that your daughter will gain by being a part of this program?
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Large
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Small
Ok
Ok
23
What are some of her hobbies & skills?
24
What are her strengths & weakness?
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Ok
25
How did you learn about this program?
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Emergency Contact Name* This field is required.
27
Home Phone* This field is required.
28
Mobile Phone
29
Email
30
Relationship to Participant* This field is required.
31
Medicare Number* This field is required.
32
Expiry Date* This field is required.
33
Doctors Name* This field is required.
34
Doctors Address* This field is required.
35
Doctors Phone Number* This field is required.
36
Health/Ambulance Fund Number
37
Does the participant have any dietry requirements* This field is required.
Yes
No
38
Please specify
39
Is the participant known to have
Diabetes
Fits of any type
Dizzy spells
Blackouts
Travel Sickness
ADHD or similar
Heart Condition
Asthma
Migraines
Epilepsy
Bed Wetting
Sleep Walking
Aspergers Syndrome
Learning Difficulties
Allergies
Other
40
Please provide details
41
Will the participant be bringing any medication to the leadership meetings/events* This field is required.
Yes
No
42
If Yes, please provide details
43
Who will administer the medication
Please Select
Please Select
Participant
Leader
Family Member
44
Has the participant had any recent illnesses or operations* This field is required.
Yes
No
45
If Yes, please specify
46
Date of participants last tetanus immunisation (if known)* This field is required.
47
Please rate the participants swimming ability* This field is required.
Please Select
Please Select
Poor
Fair
Good
Excellent
48
Is there any other information about the participant that you should disclose in order to protect their, or others, health, safety, comfort, or wellbeing?
Yes
No
49
This is the LAST question, is there anything else that we did not ask, that you want to share with us.
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Large
Normal
Small
Ok
Ok
50
If Yes, please specify
51
I understand that my registration is NOT confirmed until I have returned my signed eForm containing Consent & Payment details.* This field is required.
Yes
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