St Clement's Anglican Church Enrolment
Youth and Children's Enrolment Form
Family Details
Last Name *
Address *
Suburb *
Post Code *
Emergency Contact One Details
Name of Emergency Contact One *
Relationship to Youth Child of Emergency Contact One *
Emergency Contact One Email *
Emergency Contact Two Details
Name of Emergency Contact Two *
Relationship to Youth Child of Emergency Contact Two *
Emergency Contact Two Email *
Is there anyone legally restricted from seeing your child(ren)? *
If yes to above please give any details which would be helpful for us to know
Photos/ videos of my child(ren) may be used to advertise the group: *
Family Health Details
Medicare Card Number *
GP (if applicable) Name and Contact Number
Private Insurer (if applicable) and Membership Number
By accepting these conditions I indicate my willingness to permit my child to participate fully in activities associated with Youth and Children’s Ministry at St Clement’s Anglican.
• In the case of a medical emergency I give my permission for a doctor chosen by a St Clement’s Anglican leader or other person supervising to secure proper treatment for and/ or order hospitalisation, injection, anaesthetic or surgery for my child as named. I understand that every effort will be made to contact me prior to instituting such procedures.
• I agree that the information included on this form can be used by leaders of Youth and Children’s Ministry or any other authorised person supervising for the purposes of St Clements ‘s Children and Youth Ministry.
• I understand that children or youth attending programs must be signed in and out weekly by an authorised adult. I agree to notify the leaders at St Clement’s Anglican of the names of any other authorised adults who can pick up my child.
By ticking the below checkbox I accept these conditions. *
In addition to the above information please tick this box if you would like to be contact to discuss anything on this form further in person or over the phone. *
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