Bull Creek Youth Registration 2022Bull 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 6149Please enable JavaScript in your browser to complete this form.Surname *Given Name *Date of Birth *Gender *MaleFemaleSchool Year *School Attending *Home Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryParent/Guardian DetailsParent/Guardian Name *FirstLastFirstLastParent/Guardian Contact Number *Parent/Guardian Email Address *Does your child/ward live with you? *YesNoParent/Guardian Home Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryUnder 18 Medical Form and Authorisation FormMedicare Card Number *Please include position number i.e 1, 2 3 etcMedicare position number e.g 1,2,3 *Do you have a Private Health Fund? *YesNoName of Health Fund Provider *Health Fund Number *Do you have ambulance cover? *YesNoAllergiesDoes the attendee have any allergies? *YesNoSelect any allergies that apply *PenicillinBee stingsBetadinePain relief medicationFood allergiesOtherPlease list food allergies *Please list other allergies *Does the person attending require an adrenalin pen? *YesNoPlease note, if you have anaphyaxis you are required to carry your own epipen.Does the person attending have any medical conditions? *YesNoPlease select any medical conditions that apply *AsthmaDiabetesOtherPlease list other medical conditions *Dos the person attending need to use regular medication? *YesNoPlease list any medication that requires self-administration *Emergency Contact InformationContact person in case of emergency *Relationship to child *Emergency contact number *Alternative contact person in case of emergencyRelationship to childEmergency contact numberConsentsI consent that WPCBC may use photos and/or video footage of my child/ward for the WPCBC website/newsletter/other publications *YesNoI 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 *YesI 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 *YesIndemnityIn 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 *FirstLastSignature of Parent/Guardian *Clear SignatureDate *PhoneSubmit