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*

MaleFemaleOther
Education
Please tick the highest level of education*

No educationAttending Pre-PrimaryAttending PrimaryCompleted Year 9Completed Year 10Completed Year 11Completed Year 12DiplomaBachelor DegreeMaster DegreePhD/HigherOther
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
I understand and accept that by signing this agreement I give consent to KaaHoots Therapeutic Services (KTS) to receive and share my personal information when relevant to my careI understand and have read the Privacy and Confidentiality Information Sheet – how my information will be collected and usedI am confident that I understand the information and conditions described in this form
Full name*

First NameLast Name
Relationship to Child (if applicable)
Date

DayMonthYear
Date
Signature

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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