Youth Ministry Personal Details Form

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Please understand that you are registering your child/children to the Youth ministries of the Yeppoon Wesleyan Methodist Church* This field is required.
One Eighty Youth
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Please understand that you are registering your child/children to the Youth ministries of the Yeppoon Wesleyan Methodist Church* This field is required.
I Understand
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Family Name* This field is required.
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Name/s of child/children you are registering for* This field is required.Given Names and Birth Date
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* This field is required.Given Names
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* This field is required.Date of Birth
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Address* This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Parent/Guardian Name* This field is required.
First Name
Last Name
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Parent/Guardian Phone Number (Land Line)Land Line if you have one
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Parent/Guardian Mobile Phone Number
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Parent/Guardian Email* This field is required.
example@example.com
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Does your child have their own phone number?* This field is required.
YESNO
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Please add your child's mobile phone number if you wish for us to have it?
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Please add your child's/children's mobile phone number/s if you wish for us to have it?
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Additional Emergency Contacts* This field is required.
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Emergency Contacts email* This field is required.
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Additional Emergency Contact* This field is required.
First Name
Last Name
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Emergency Contact Phone Number (Land Line)Land Line if you have one
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Emergency Contact Mobile Phone Number
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Emergency Contact Email
example@example.com
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I would like to authorise other people to collect and drive my child/children home from {selectThe}* This field is required.If you select 'NO' in this question, our leaders will ensure that only the parent or guardian picks up your child/children. You may update these details by contacting your ministry leader. if you select 'YES', you will be asked for name and phone numbers of those, other than parents or guardian, you authorize to collect your child/children. If you need more room, please contact the office with the extra names.
Yes
No
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I authorise First Name * Last Name * to bring my child/children home from {selectThe}. Their contact number is Phone Number *
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Would you like to authorise more people?
YES
NO
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I authorise    First Name     Last Name    to bring my child/children home from the Youth program. Their contact number is Phone Number

I authorise    First Name     Last Name    to bring my child/children home from the Youth program. Their contact number is Phone Number

I authorise    First Name     Last Name    to bring my child/children home from the Youth program. Their contact number is Phone Number

I authorise    First Name     Last Name    to bring my child/children home from the Youth program. Their contact number is Phone Number
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Are there any court orders or custody issues relating to your child/children?* This field is required.
Yes
No
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Please give details of any court order or custody issuesThis information will only be used to ensure the protection of your child/children
Huge
Large
Normal
Small
Ok
Ok
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Are there any medical conditions or impairments that may affect participation or safety (including allergies and long term medication/s) relating to your child/children?* This field is required.
Yes
No
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Please write down any medical conditions or impairments that may affect participation or safety (including allergies and long term medication)
Huge
Large
Normal
Small
Ok
Ok
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Media Permission* This field is required.I give my permission for my child/children's photo to be taken for use in Church bulletins, Church web page, YouTube, newspaper releases or any other activity that may happen at the youth programs I also understand that my child/children's photo will not be given to any other person or organisations for purposes other than the use of the Yeppoon Wesleyan Methodist Church.
YESNO
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Declaration* This field is required.I {parentguardianName} acknowledge that risk of injuries is possible in all physical activates. While I am aware that leaders will take all due care, I understand that accidents may occur. I give my permission for the leaders of {selectThe} to apply first aid and to contact an ambulance in a medical emergency. I understand that my child is not covered by Accident insurance under the Yeppoon Wesleyan Methodist Church and acknowledge if I would like my child covered by accident insurance I will organise our own personal accident policy. I understand that the leaders and supervisors will endeavour to ensure the safety and well being of all {selectThe} attendees and that unsafe behaviour and/or misconduct shown by any young person will not be tolerated. In this case the young person will be asked to sit out of activities. If this persists the parent will be contacted. I recognise that if my child/children are demonstrating this behaviour that I may have to come and pick them up from {selectThe} .
Accept
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Covid-19 Statement* This field is required.By registering your child/children to '{selectThe}' you acknowledge that your child/children does not have any symptoms associated with COVID-19 (e.g. fever, cough, sore throat, shortness of breath, sneezing/runny nose or loss of sense of smell), your child/children does not have COVID-19 nor are they awaiting the results from being tested for COVID-19, your child/children have not been in contact with any known or suspected cases of COVID-19 in the past 14 days, your child/children have not returned, or been in contact with anyone else who has returned, from overseas in the past 14 days, and, understand that your child/children are required to stay home if they are unwell. Your child/children also understand that if social distancing measures are required by law, then these will be strictly followed upon arrival to the premises during that time for those who are part of our '{selectThe}'
Yes
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Sign using mouse (or finger/stylus on touch screens). Please sign within the box* This field is required.
Should be Empty: