City Youth Sign-in
Parents Details
Parent Name (if you have already filled our this form for another child, please just put your name & skip to the child details)
Parent Contact Number
Parent Email
Home Address
Child Details & Medical information
Name
Gender
D.O.B
MM
/
DD
/
YYYY
Emergency Contact Name (if parent can't be reached)
Emergency Contact Phone
Medicare Number
Medicare Card Reference Number
Medicare Card Expiry
Any allergies or medication?
If your Child on a special diet, on any medication (not already noted), have a serious illness or disability, have a known behavioural problem or restricted from any activity? If yes to any of the above, please provide details
Is there anyone who is legally restricted from seeing your child?
Clear selection
If yes, what is their name?
Do you give permission for photos/videos of my child to be taken that may be used to advertise City Youth?
Clear selection
Do you give permission, in the case of a medical emergency, to the doctor chosen (either by the church authorities or other persons supervising or administering the activities), to secure proper treatment for and/or order hospitalisation, injection, anaesthetic or surgery for my child as named. Every effort will be made to contact you prior to instituting such procedures.
Clear selection
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