ALTITUDE Registration Form • C@P & CCM

YOUTH GROUP REGISTRATION FORM

CHILD DETAILS

First Name *

Last Name *

Gender *

Date of Birth *

School Grade *

Is there anyone who is legally restricted from seeing the child? *

Name of restricted person *

Does the child have any allergies? *

Please specify allergy details *

Does the child have any special dietary requirements? *

Please specify dietary requirements *

Does the child have any medical conditions or disabilities that would be helpful for the leadership team to be aware of? *

Please specify medical condition or disability *

Does the child take any regular medication that would be helpful for the leadership team to be aware of? *

Please specify medications *

May the child require spontaneous medication (e.g., asthma puffer, Epipen, etc.)? *

Please specify spontaneous medication *

PARENT/GUARDIAN DETAILS

Relationship to Child

First Name *

Last Name *

Mobile Number *

Email Address *

Address Line 1

Address Line 2

Suburb

State

Postcode

SECONDARY CONTACT DETAILS

First Name *

Last Name *

Mobile Number *

Relationship to Child *

TERMS & CONDITIONS

I hereby give permission for my child to participate fully in the Youth Group's ministry activities associated with Church@thepeak and Christ Church Mortdale held during school term on Friday nights between 7pm and 9pm (located at 110 Morts Road, Mortdale). *

Yes

In the case of a medical emergency, I hereby give permission to the medical professionals chosen by the church authorities and/or youth leadership team to secure the appropriate and proper treatment for my child. *

Yes

I consent to having my child photographed and/or videoed during regular Youth Group activities and irregular activities (i.e., camps, conferences, and off-site social nights), and that any photo and/or video footage of my child obtained will not be publicly distributed but may be used for promotional purposes by Church@thepeak and Christ Church Mortdale. *

Yes

Please note that our leadership team will treat the information given in this form confidentially. This information may be shared with a third party when it concerns medical health or care of the individuals listed. If you wish to access this information or have any queries in relation to the manner in which we handle your personal information, please do not hesitate to contact me.

Dan E. Tooma

0416 969 957

dan@churchatthepeak.org.au

Please visit either of the following websites for more information:

https://www.churchatthepeak.org.au

https://christchurchmortdale.org.au