Under 18 Registration Form

Participant Details

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

What ministry/ministries will your child be involved in? *

Creche (babies and toddlers)

JFC (3 years-grade 7)

Youth (grades 7-12

Tip: If unsure, base your answer on the age group

Home Address

Home Address *

Home City *

Home Postcode *

Postal Address

Postal Address Same as Home Address

School Info

School

School Grade

Custody

Is there a Custody Order regarding this young person?

Parent/Guardian Details

Person 1

Relationship to child *

Tip: Eg. Father, mother, etc.

Given Name *

Surname *

Landline

Mobile

Email Address

Address

Person 2

Relationship to child

Tip: Father, mother, etc.

Given Name

Surname

Landline

Mobile

Email Address

Address

Medical Information

Emergency Contacts

Other than parents/guardians (just in case primary caregivers are unavailable).

Emergency Contact 1 (Other than primary carer)

Emergency Contact 1 - Name

Emergency Contact 1 - Number

Emergency Contact 1 - Relationship

Emergency Contact 2 (Other than Primary Carer)

Emergency Contact 2 - Name

Emergency Contact 2 - Number

Emergency Contact 2 - Relationship

Medical Cover

Medicare Details

Medicare Number *

Medicare Position *

Medicare Exp *

Private Health Insurance

Do you have Private Medical Insurance *

Permissions

Media & Photography Consent

Video footage and photographs are taken to record church ministry events, including Church Services, Creche, JFC, and Youth, and may be used by Dalby Baptist Church and its associated ministries in documents and media such as print or digital communication.

Photo/Video Use Approval *

Other Comments or Information

Are there any other comments you would like to add?

Other Info

Acknowledgement

I/we understand that every effort will be made to provide a safe environment for my child to participate in. However, in signing this form I authorise the leaders, in the event of an emergency, to obtain at my/our expense, any medical, ambulance or similar services considered necessary by the leaders.

I/we recognise that being a part of a community involves mutual care and consideration and therefore agree that unacceptable behaviour may result in our being called to address inappropriate behaviour and/or my Youth being sent home and/or being temporarily or permanently prohibited from attending the youth activities.

Name *

Date Submitted*