Medical form 2023

Child details

First Name *

Last Name *

Gender *

Date of Birth *

School Grade in 2023 *

Medical details - please leave empty if none exist

Give a short description of any dietary requirements.

Give a short description of any allergies.

Does the child need to take any medication during the program?

Are there any other Medical/Behavioural Conditions we need to be aware of?

Is there any other information we need to know (i.e. custody order)?

Medicare Number (please enter numbers only, no spaces or / ) *

If no medicare number exists, please enter 000 and give a reason in the 'other information' field.

Other details

Photos/videos may be taken during the programs by designated team members which could be displayed in a public place (e.g. church publication, presentation, internet site, Facebook page).

Do you give permission for photos and videos to be taken of the attendee? *

Are there any specific activities you do not want the attendee to participate in?

Parent/Guardian details

Parent/Guardian Name *

Parent/Guardian Mobile Number *

Email Address *

Home Address *

Home Suburb *

Home State *

Home Postcode *

Emergency contact details

First contact in emergency (name) *

First contact in emergency (phone) *

Second contact in emergency (Name) *

Second contact in emergency (phone) *

Other programs

Which programs will your child attend at Willows during the year?

Programs permission *

Terms and Conditions

I give permission for the personal details given herein to be provided to appropriate leaders and/or relevant medical/emergency services as deemed necessary. I understand the details given herein will be used by leaders to contact myself and/or my child/ren and that the details will not be given to any third party, except as provided above.

By completing this form, I hereby give permission for my child/ren to attend all scheduled activities, unless we explicitly advise the leadership team otherwise. In doing so I undertake to provide the leaders with any information relevant to the wellbeing of my child/ren prior to them attending any and all scheduled activities.

Willows Presbyterian Church