Holiday Kids Club 2018 Registration
Tuesday 10 - Thursday 12 April 2018
9am-12:30pm
Central Church Ipswich
20 Limestone Street, Ipswich
hkc@centralchurch.net.au
Email address *
Family Information
Parent/Guardian 1 Name *
Your answer
Parent/Guardian 1 Phone Number *
Your answer
Address *
Your answer
Parent/Guardian 2 Name
Your answer
Parent/Guardian 2 Phone Number
Your answer
Address
If different to Parent 1
Your answer
Parent/Guardian 2 Email
Your answer
People who have permission to drop off/collect my child/children
Your answer
Child 1 Information
Name
Your answer
Birth date
MM
/
DD
/
YYYY
School Grade
Are there any medical or psychological conditions that require special attention that we should know about e.g. medications, allergies, hearing or sight impairment, behaviour issues or a mental health plan? *
Please include details
Your answer
Child 2 Information
Name
Your answer
Birth date
MM
/
DD
/
YYYY
School Grade
Are there any medical or psychological conditions that require special attention that we should know about e.g. medications, allergies, hearing or sight impairment, behaviour issues or a mental health plan?
Please include details
Your answer
Child 3 Information
Name
Your answer
Birth date
MM
/
DD
/
YYYY
School Grade
Are there any medical or psychological conditions that require special attention that we should know about e.g. medications, allergies, hearing or sight impairment, behaviour issues or a mental health plan?
Please include details
Your answer
Child 4 Information
Name
Your answer
Birth date
MM
/
DD
/
YYYY
School Grade
Are there any medical or psychological conditions that require special attention that we should know about e.g. medications, allergies, hearing or sight impairment, behaviour issues or a mental health plan?
Please include details
Your answer
Child 5 Information
Name
Your answer
Birth Date
MM
/
DD
/
YYYY
School Grade
Are there any medical or psychological conditions that require special attention that we should know about e.g. medications, allergies, hearing or sight impairment, behaviour issues or a mental health plan?
Please include details
Your answer
Permissions
Anything else we need to know
Your answer
I give permission for my child to walk up to Queens Park for games with the leaders. *
Required
Can we take appropriate photos & video of your child/ren to use in house by Central Church Ipswich? *
Required
Can we use group photos without names on our website & social media? *
Required
Your agreement with Presbyterian Church of Queensland (PCQ): You acknowledge the following: 1. I understand that although the leaders will take all reasonable care to ensure both the comfort and safety of my child, there is still a risk that an accident may occur. I understand that in the event of an accident, the leaders will undertake all reasonable emergency care, including seeking ambulance and professional medical treatment. 2. By ticking the box below, you certify that all of the information you have provided is correct and you understand your agreement with us as set out above. 3. You confirm that the information contained in this online registration is true and correct. 4. You agree to inform the Holiday Kids Club Director of any change to these details. You are welcome to contact our office (07 3413 1050) in relation to issues regarding your personal information. *
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