HTY Indemnity form 2019-A

Details of Child

First Name *

Preferred Name

Last Name *

Home Address

Home City

Home Postcode

Date of Birth *

Gender

School Grade *

School:

Church attended previously (including suburb)

For the purposes of communicating with your child (i.e. for invitations and reminders of events), feel free to include the following details:

Email Address

Mobile Number

Child's Health Information

Family Doctor (name, practice and suburb)

Family Doctor Phone:

Medicare No. (including reference number)

Medicare Expiry

Emergency Contact Name (if parent can not be reached): *

Emergency Contact Number (if parent can not be reached): *

Allergies and Medications

If your child has any allergies or takes medications please explain these below (include dosage and who is to administer medication, child or leader?)

Special Needs

Does your child require a special diet, take any medication (not already noted), have a serious illness or disability, have a known behavioural problem or need to be restricted from any activity? *

If yes, please note details below

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

Who?

Photo/video permissions

I give permission for photos/videos of my child to be taken that may be used to advertise the group. (HTY advertisements are mostly internal). (Please discuss advertising and use of Instagram with Geoff) *

I give permission for photos/videos of my child to be up loaded to the 'private' Instagram account. All Instagram photos are saved. If you wish, follow our account @htysnaps *

Details of Parent/Guardian

Full name:

Address (if different from above), including postcode:

Ph(home):

Ph(work):

Ph(mobile):

Email:

PARENT/GUARDIAN PLEASE READ, SIGN AND DATE THE FOLLOWING:

My signature below indicates:

My willingness to permit my child to participate fully in the Holy Trinity Youth activities on Friday nights.

That I give my permission, in the case of a medical emergency, to the doctor chosen (either by the church authorities or other persons supervising or administering the activities), to secure proper treatment for and/or order hospitalisation, injection, anaesthetic or surgery for my child as named. I understand that every effort will be made to contact me prior to instituting such procedures.

Parent or guardian’s signature certifying acceptance of all these conditions:

Signature (box to be signed once form is printed)

Date signed

The information in this letter will be keep confidential. This information may be shared with a third party when it concerns medical health or care of the individuals listed. Please don’t hesitate to contact us with any queries in relation to this information.

Email: youth@holytrinitydoncaster.org.au Phone: 0419 463 514 (Youth Pastor)