WELS - Registration Form & Medical Information - Members 2016/17
Thank you for joining our program. Thank you for completing the registration and medical form below. If you have any further questions or wish to pass on any other information please contact us.
Child/Participant's Name *
Your answer
Date of Birth *
Your answer
Parent/Gaurdian Name 1 *
Your answer
Contact Number *
Your answer
Contact Email *
Your answer
Address *
Your answer
December 2016
December 19- 21/23 Trinity Grammar, Kew - Leadership Programs: Middle Years & Junior
Select the option you wish to confirm your registration for and leave the other options blank.
January 2017
Below is a list of all our programs this month. Please select the program you wish to confirm your registration for.
Parent/Gaurdian Name 2
Your answer
Additional Emergency Contact Name *
Your answer
Relationship to Participant *
Your answer
Additional Emergency Contact Phone Number *
Your answer
Language Spoken at Home
Your answer
Health/Medical/Special Needs
Do/es your child/children have any health, medical and special needs we need to be aware of during the program. If yes, select yes and provide details below. *
Please list any food allergies or sensitivities and provide details of treatment plan
Your answer
Does your child carry the appropriate medication to treat an allergic reaction (provide details)?
Your answer
Does your child have any medical conditions that are relevant for activities of a physical nature? (Please describe):
Your answer
Please list any medications your child is currently taking:
Your answer
Any other special requirements or needs we should be aware of about your child (include social, religious or cultural requirements):
Your answer
Swimming - my has my consent to swim and participate in water based activities? *
Required
Swimming Ability *
What is your child's swimming ability?
Required
Do you have Ambulance cover? *
Medicare Number *
Your answer
Do you have private health insurance cover for your child? *
What is the name of your provider?
Your answer
Drop off & Pick up Arrangements
Pick up and drop off arrangements for my child *
Required
Name of person/people responsible for picking up and dropping off your child (if different from parents or legal guardian)
Your answer
Contact number of person/people responsible for picking up and dropping off your child (if different from parent/gaurdians listed above)
Your answer
Parent/Guardian Consent - I acknowledge the information contained here will be treated as confidential. I understand it will be made available to staff or health care professionals who have a duty of care while my child attends WELS programs. I have read and understand the information about the programs and provide my consent for my child/ren to participate in all programs and all activities and components of the programs. I accept that there will be activities of a physical nature and voluntarily and expressly waive any injury claim against the WELS School, Director, Ben Righetti, Program Coordinators and any other staff or volunteers assisting with the program. In the event of an injury, if I am unable to be contacted I also authorise the WELS School, Directors, Ben Righetti or the Program Coordinators to arrange medical treatment as necessary. *
Signed (please note: by typing my name below I acknowledge I am the legal guardian of the participant being registered and that by my name below is representative of my signature) *
Your answer
Date *
Your answer
Photo and Video Consent - I consent to photo or video of my child taken during the program, and future programs run by the WELS School, being used to help improve the program, and for promotion and communication purposes. I understand that in all cases my child will not be personally identified in any way. *
I am interested in receiving information about the other WELS School programs, camps, activities and courses. *
How did you find out about us? It is so important for us to find out how your first heard about us and why you signed up *
Required
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