YouthZone Registration Form
Simpson Barracks Community Centre
1 - Child Name
*
First Name
Last Name
Age
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
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December
Month
Please select a day
1
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
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2015
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2012
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Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Grade Level
Health Insurance Provider Name & Number
*
Medicare Card Number (Inc Reference and Exp)
*
Does the child have any allergies or medical conditions we need to be aware of?
*
Yes
No
If Yes, please provide details and Health Management Plan below, so we are best able to care for your child in case of an emergancy.
*
I give permission for my child to be photographed or videoed for use in SBCC internal and external marketing, advertising and promotions. Including Newsletters, social media posts, marketing materials etc.
*
Yes
No
Parent/Guardian Information 1
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship
*
Parent/Guardian Information 2
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship
*
Serving Members Unit
*
Acknowledgment
I acknowledge that the events are run by volunteers of the SBCC, giving freely of their time. I, therefore, acknowledge that respectful communication will be given at all times and, in available circumstances, notify the event coordinator where my child may be late in attendance or to be picked up from an event.
I acknowledge that there will be a 30-minute grace period if the child is not picked up by the stated completion time of the event and contact is unable to be made with Parents/Guardians that the authorities will be contacted.
I acknowledge that SBCC has a zero-tolerance policy for harassment and bullying. If my child is identified in such a matter, after discussion with staff, my child may be asked to end that night's activities early. If my child repeats these offences, it may result in suspension or expulsion from the group.
I acknowledge that I may need to sign additional waivers for particular activities held on or off base.
I acknowledge that I must sign my child in and out of every event.
At least one Parent/Guardian registered in this form has legal custody over the child.
For medical emergencies, I allow the medical team of this organisation to take care of my child and travel with them to the nearest hospital by ambulance should the occasion arise.
I release this organisation and its volunteers from any and all liability from accident or injury to the child during the organization-related events.
Costs for Youth Group activities are subsidised under the SBCC Membership, and understand that I will pay associated costs for individual activities if I do not hold a current SBCC Membership
I have paid and hold a current SBCC financial Membership
*
Yes
No
Parent/Guardian Signature
*
Child's Signature (Acknowledgment of zero tolerance to bullying and harassment)
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: