Bull Creek Youth 2022 rego - Westminster Presbyterian Church Bull Creek

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Westminster Presbyterian Church Bull Creek

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Bull Creek Youth Registration 2022

Bull Creek Youth is an activity of the Westminster Presbyterian Church Bull Creek Inc. (WPCBC). The activities include, but are not limited to: Bible studies, games and organised activities. Bull Creek Youth is primarily held at WPC Bull Creek, 32 Bull Creek Drive, Bull Creek, WA 6149

Surname *

Given Name *

Date of Birth *

Gender *

Male
Female

School Year *

School Attending *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/Guardian Details

Parent/Guardian Name *

First

Last

First

Last

Parent/Guardian Contact Number *

Parent/Guardian Email Address *

Does your child/ward live with you? *

Yes
No

Parent/Guardian Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Under 18 Medical Form and Authorisation Form

Medicare Card Number *

Please include position number i.e 1, 2 3 etc

Medicare position number e.g 1,2,3 *

Do you have a Private Health Fund? *

Yes
No

Name of Health Fund Provider *

Health Fund Number *

Do you have ambulance cover? *

Yes
No

Allergies

Does the attendee have any allergies? *

Yes
No

Select any allergies that apply *

Penicillin
Bee stings
Betadine
Pain relief medication
Food allergies
Other

Please list food allergies *

Please list other allergies *

Does the person attending require an adrenalin pen? *

Yes
No

Please note, if you have anaphyaxis you are required to carry your own epipen.

Does the person attending have any medical conditions? *

Yes
No

Please select any medical conditions that apply *

Asthma
Diabetes
Other

Please list other medical conditions *

Dos the person attending need to use regular medication? *

Yes
No

Please list any medication that requires self-administration *

Emergency Contact Information

Contact person in case of emergency *

Relationship to child *

Emergency contact number *

Alternative contact person in case of emergency

Relationship to child

Emergency contact number

Consents

I consent that WPCBC may use photos and/or video footage of my child/ward for the WPCBC website/newsletter/other publications *

Yes
No

I authorise the WPCBC leaders/volunteers, ministers, elders, deacons in charge, where it is impractical to communicate with me, to arrange for medical treatment for my child/ward as deemed necessary by a qualified medical practitioner *

Yes

I authorise the use of ambulance for my child/ward should it be deemed necessary and authorise the use of anesthetics by a qualified medical practitioner if in his/her judgment it is deemed necesary *

Yes

Indemnity

In my child/ward attending Bull Creek Youth, I undertake the following:

I, the undersigned agree that in the event of requiring medical attention, I acknowledge that any costs incurred will be my responsibility and I agree to reimburse WPCBC and its employees and/or volunteers for all costs which they incur on my behalf.

I agree that my child/ward will abide by the rules, guidelines and instructions given by WPCBC and/or its employees, volunteers, pastors, elders, deacons in charge, in respect of the activity.

I accept all reasonably forseeable risks associated with the Bull Creek Youth program and activities. I acknowledge that this acceptance is a condition precedent to my child/ward taking part in any capacity in the Bull Creek Youth program and activities.

I hereby release, hold harmless and forever discharge WPCBC, the Bull Creek Youth leaders and church leaders against any claim whatsoever arising out of or related to any forseeable loss, property damage or personal injury that may be sustained by my child/ward or to any property belonging to my child/ward while in attendance of the duration of the program.

I agree that this document may be pleaded in bar to any claim arising from risks normally associated with the activity, made by or on behalf of my child/ward or my executors, administrators or other personal representatives arising out or in respect of the WPCBC church and its Bull Creek Youth Group.

The indemnity and release contained in this document will be enforceable against me and my executors, administrators and other personal representatives.

I certify that this information is true and correct to the best of my knowledge and that it will be valid for Bull Creek Youth weekly meetings and one off events throughout the year shown at the top of this form. I understand that failure to disclose changed or new information to WPCBC and Bull Creek Youth and its leaders, volunteers and helpers will be at my and my child's/ward's own risk and in no way be the responsibility or fault of Bull Creek Youth or WPCBC if information is not disclosed.

Name of Parent/Guardian *

First

Last

Signature of Parent/Guardian *

Date *

Email