Childs Surname
Child's Name
First Name
Last Name
Preferred Name
Gender
Date of Birth
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
Email Address
Do you consent to appropriate use by us of photographs taken on the program that include your child e.g. inclusion in our newspaper, placement on our web page or in a brochure?
Does your child have any special dietary requirements?
If so, please list them: (We will endeavour to meet these requirements, and will contact you if necessary)
Can your child swim?
In case of an emergency, please list phone numbers where you and a friend or relative may be contacted during the course of the program. (please list name, relationship, & phone number) (please list 2)
List two emergency contacts
Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment, ADD or ADHD, behaviour issues, formal counselling situations, or any other?
Insurance Provider
Membership Number
Medicare Number
Number of person on Medicare Card
Expiry Date
Health Care Card Number (if applicable)
Will your child need to take any tablets or other medication during the course of the program?
If yes, please give details
Has your child been taken off medication recently?
If yes, please give details
Has your child previously broken/fractured any bones?
If yes, please give details
What is the year of your child’s last tetanus injection?
Are there any specific activities that you do not wish your child to participate in?
If yes, please specify
Has your child suffered from any conditions in the past or the present that we should be aware of (including asthma, bronchitis, diabetes, ear infections, epilepsy, fits/convulsions, fainting/dizziness, glandular fever, hyperactivity, heart problems, measles, mumps, pneumonia, tonsillitis, allergies)?
Details: e.g. severity, last injection, treatment
Name of Caregiver
First Name
Last Name
If other than a parent or guardian, please indicate relationship to child
