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FBCLumberton Teamkid Registration
Personal Contact Details
Family Member Name/s *
Your answer
Child's Name *
Your answer
Child's Date of Birth *
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Preferred name
Your answer
Address *
Your answer
Phone *
Your answer
Email
Your answer
Alternate Emergency Contacts:
Name/ Relationship to Child/ Phone *
Your answer
Name/ Relationship to Child/ Phone
Your answer
Please give details (name, address and phone number) of other persons who you authorise to collect your child/ren in your absence, while in the care of the above-named group: *
Your answer
Are there any family situations we should be aware of ? Eg: custodial issues, other matters (please specify) *
Your answer
Privacy Information
All the information recorded on this form is collected and managed in accordance with the Uniting Church Privacy Policy. This information has been collected for the primary purpose of FBCL and may be used for any activities conducted or promoted by FBCL .
If you do not want this information to be used for any other purpose other than children’s programs, please notify us in writing:
FBC Lumberton Children’s Ministry
PO Box 8067
Lumberton, TX 77657
Permission to Participate in Program Activities I consent to my child taking part in the approved program of activities for Teamkid. *
Required
Permission to View Video Tapes and DVDsI consent to my child viewing VHS tapes or DVDs rated (G) General.I understand that all material will be previewed by a leader to check suitability. *
Required
Permission to be Photographed or Filmed I give my permission for my child to be photographed or videotaped. I understand that the image may be displayed in the church publications, church buildings or website. I understand that as a precaution my child’s name will not be published or linked with photographs.
Confidential Medical Report
The information below is requested to assist in case of any illness or accident. This information will be held in confidence.
1. Please check if your child suffers from any of the following:
2. Is your child presently taking medication? Yes / No If yes, please state the name of the medication, dosage, etc. *
Your answer
Does your child self-administer their medication?
Does your child have any Allergies? *
Your answer
Please list any physical or special needs: (eg. Dietary requirements) *
Your answer
I authorise the leader/s in charge of the above mentioned group where it is impractical to communicate with me, to arrange for my child to receive such medical or surgical treatment as the leader/s may deem necessary at any time during the activities of FBC Lumberton.I further authorise the use of Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment.I appreciate that every care will be taken by the leaders and those connected with that group cannot be held responsible for personal injury, loss or theft of property affecting my child.
Date: *
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Signature: *
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