Peninsula City Youth (PCY) Registration Form

PCY Attendee's Personal Information
Full Name*
D.O.B*

DayMonthYear
Date
Gender
Year Level*
School*
Do you currently attend a church?*

NoYes
If you are attending a church, please tell us which church you call home.*
Address*

Home Address

Street Address Line 2

SuburbState / Province

Postal / Zip Code
Postcode*
Email
example@example.com
Phone (h)
Phone (m)
Doctor Name*
Doctor Name*
Doctor Phone number*
Medicare Card No*
Number/Position on Medicare card*
Ambulance No
Health Insurance Provider
Health Insurance No
Date of last tetanus immunisation*
Medical/Additional Needs Information*

NoYes*

Does this person have any medical conditions or allergies we need to be aware of?*

NoYes

Medical/Allergy Management Action Plan 2024
Please upload a photo of your child for their Medical/Allergy Management Plan

Cancelof
Medical Condition/Allergy
Causes/Triggers:
Signs and symptoms:
Treatment/Medication:
Is this child/young person able to self-administer treatment?
Please upload any Management plans you have (if applicable):

Cancelof
Is there any additional information that would be helpful for us to know about your child's medical condition/allergy?
Medical/Additional needs brief info (please complete additional needs form for more detailed information)

Does this person have any additional needs it would be helpful for us to know about?*

NoYes

Additional Needs Information 2024
Please upload a photo of your Child for their Action Plan

Cancelof
Current diagnosis, medical condition or learning difference:
Triggers, signs and symptoms of tiredness or frustration:
Management of frustration and tiredness:
My child really enjoys the following activities:
My child needs extra help with the following activities:
Please upload any Management plans you have (if applicable):

Cancelof
Is there any additional information that would be helpful for us to know about your child's additional needs?

Is there anything else the leader(s) should know about your child?
Parent/Guardian Details
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 1 Phone Number*
Please enter a valid phone number.
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Email
example@example.com
Parental Consent to seek medical attention:
If the leader in charge is unable to communicate with me, I authorise the leader in charge to consent to my child travelling in an ambulance and receiving medical or surgical attention if deemed necessary.*

NoYes
Custody Arrangements
Are there any custody arrangements you would like us to be aware of?*

NoYes
If yes, please explain
Parental Permission to take Photographs:
I hereby give permission to the Leaders to take photographs of my child while he/she participates in planned activities. I do so with the knowledge that these photos may be copied and distributed to other attendees as a memory of their involvement. I also give permission to the use of some of these photos in future advertising of Peninsula City Youth activities.*

NoYes
Parent's / Guardian's Signature*

Clear
Date*

DayMonthYear
Date
Peninsula City Church is a Child safe Church. We only collect information where it is necessary to do so to provide a service to you, or where we are required by law to do so. Access to personal information is restricted to support staff. We will not pass any of your personal details to any other organisation.

We seek to accommodate all children/Young people who wish to participate, however, our duty of care in respect to supervision ratios may mean that we are not able to provide adequate support for your child if they require constant attention by a leader to participate in our program(s).
I do not consent to my contact details being used for general Peninsula City Church Communications.
Should be Empty:

PCY Attendee's Personal Information

Medical/Allergy Management Action Plan 2024

Additional Needs Information 2024

Parent/Guardian Details