REGISTRATION FORM

REGISTRATION FORM
Participant Details
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Email
example@example.com
Mobile and/or Home Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

Other
Education
Please tick the highest level of education

Other
Name of current school/childcare
Teacher
Medical
Medicare card
Reference number
Expiry
HealthCare Card
Expiry
NDIS reference number
Are there any allergies or medical conditions we should be aware of? (please give details)
Emergency Contacts
Name

First NameLast Name
Relationship
Mobile and/or Home Phone
Name

First NameLast Name
Relationship
Mobile and/or Home Phone
Disclosure of Liability of Healthcare and Parental Authority for the Treatment of a Minor

(not applicable if participant is over 18 years old)
I, First Name Last Name , declare that I am legally responsible to make decisions about the health and well-being of First Name Last Name , date of birth DD,MM,YYYY and with this legal responsibility, give KaaHoots Therapeutic Services (KTS) permission to establish a treatment plan for the benefit of my child’s health and wellbeing.
Consent to Share Information

The people and services that I agree to share my information with are:
The people and services that I agree to share my information with are:
Name

First NameLast Name
Location
The people and services that I do not agree to share my/my child’s information with are
Full name

First NameLast Name
Relationship to Child (if applicable)
Date

DayMonthYear
Date
Signature
Should be Empty:

REGISTRATION FORM

Participant Details

Education

Medical

Emergency Contacts

Disclosure of Liability of Healthcare and Parental Authority for the Treatment of a Minor

Consent to Share Information