Registration Form
Email address *
Branch Location *
Child's Details
Surname: *
First Names: *
Date of Birth: *
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Age: *
Address: *
Post Code: *
Contact Information
Parent / Legal Guardian's Name: *
Contact Number: (home)
Contact Number: (mobile) *
Contact Number: (work)
Contact Number: (other)
If Unavailable, Please Contact: *
Relationship to Child: *
Contact Number: *
Contact Number: (other) *
Medical and Other Information
Name and Number of Child's GP: *
List all known medical conditions, including food allergies and/or drug allergies, as well as any medication being taken:
Any other special needs that may be helpful for the staff to know:
During the time your child is at Uplift, photos and videos may be taken for promotional and general purposes to include internal and external publication and Uplift websites. Do we have your permission for your son or daughter's photograph to be taken and used as indicated? *
Statement of Consent
In the event of an emergency or non-emergency situation requiring medical treatment, I *
, hereby grant permission for any and all medical attention to be administered to my child in the event of an accidental injury or illness. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, the administration of anaesthesia and/or surgery, under the recommendation of qualified medical personnel. If I cannot be contacted and my child should require emergency hospital treatment, I authorise a member of the Uplift staff to sign on my behalf any written form of consent required by the hospital. However, I understand that every effort will be made to contact me as soon as possible. By submitting this form, I *
, also realise that I am agreeing to not hold Uplift or any of its staff or volunteers responsible for any injuries that my child may sustain while taking part in the Uplift program. I understand that my child is participating in this program at his/her own risk. Signature: (of parent if child is under 18 years old) *
Date *
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Relationship to Child: *
For Your Information
The information you provide will not be given out or used for any purpose other than that of Uplift records. Please note, your email will be added to our mailing account to keep you updated about events, classes and other info.
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