Roar Mt Pleasant Uniting Church Holiday Club October 2019

Holiday Club Mt Pleasant Uniting Church Tuesday 1st to Friday 4th October 2019 9am - 4pm daily
PROTECTING YOUR PRIVACY

Protecting your privacy is important to us. The information we seek allows us to manage risk, provide reasonable care and administer your involvement in our Holiday Club. We are careful to keep your information confidential, and provide it only to those agents acting on behalf of the organisation who need it to enable them to perform their agreed activities (e.g. the First-Aider-In-Charge). You are welcome to contact our office in relation to issues regarding your personal information .

We only ask for information that is necessary for the purposes outlined in this statement.
Which days of the Holiday Club will your child/children be attending?

Tuesday 1st October Wednesday 2nd October Thursday 3rd October Friday 4th October
How many children are you registering?
Child Information
First Child
Child's Name *

First Name Last Name
Child's Birth Date *

Month Day Year
Current Year at school *
Medical or other information we may need to know about the child (including food allergies). *
Second Child
Child's Name *

First Name Last Name
Child's Birth Date *

Month Day Year
Current Year at school *
Medical or other information we may need to know about the child (including food allergies). *
Third Child
Child's Name *

First Name Last Name
Child's Birth Date *

Month Day Year
Current Year at school *
Medical or other information we may need to know about the child (including food allergies). *
Fourth Child
Child's Name *

First Name Last Name
Child's Birth Date *

Month Day Year
Current Year at school *
Medical or other information we may need to know about the child (including food allergies). *
Child Release Information
Parent/Legal Guardian Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email address *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Names of Persons to which the child (children) may be released to each day after Holiday Club (Please provide at least two) *

First Name Last Name
Full Name *

First Name Last Name
Full Name

First Name Last Name
Full Name

First Name Last Name
Are there any persons to which the child (children) may NOT be released to? *

Yes No
Who may you child (children) NOT be released to?
Emergency Contact 1 (other than parent/guardian listed above) *

First Name Last Name
Emergency Contact 1 Phone Number *

Area Code Phone Number
Emergency Contact 2 (other than parent/guardian listed above) *

First Name Last Name
Emergency Contact 2 Phone Number *

Area Code Phone Number
Medical Information

Please give details of your family's medical insurance if applicable. If you have completed this information before for Holiday Club and it has not changed there is no need to complete this section.
Insurance Provider

Company Membership number
Medicare Information

Medicare Number Expiry of card
Do you have ambulance cover?
Click to edit
Health Care Card (if applicable)

Number Expiry of card
Important: Please note that in regards to non-prescription medications such as paracetamol (e.g. Panadol), it is our policy that team members do not provide medications. Will any of your children need to take any tablets or other medication during the course of the program? If yes, please give details and indicate family member:
Media/Photography Release
By clicking the box below, I hereby Give Permission for photographs and/or video in which my child appears in to be used by the GFS/KidsPlus in printed and/or electronic media, including our website, Facebook etc. *

I Agree
Your Agreement with the Organisation I am aware in signing this document in regards to my family's participation in this program that certain inherent risks and dangers exist in the activities in which my family will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise exposure to known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the organisation, its leaders and staff. In the event of any emergency where my nominated contact people are unavailable: 1. I authorise the leaders to obtain medical advice and/or assistance which they deem necessary. 2. I further authorise qualified practitioners to administer anaesthetic if required. 3. I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary. 4. I accept the responsibility for payment and agree to pay medical, transport and any other related expenses. 5. I confirm that the information contained in this document is true and correct. *

I Agree
Parent/Guardian

First Name Last Name
Should be Empty:

Holiday Club Mt Pleasant Uniting Church Tuesday 1st to Friday 4th October 2019 9am - 4pm daily

Child Information

Child Release Information

Medical Information

Media/Photography Release