Hope Youth 2024 Registrations - Westminster Presbyterian Church Bull Creek

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 *

Under 18 Medical Form and Authorisation Form

Allergies

Does the attendee have any allergies? *

Yes
No

Select any allergies that apply *

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 serious medical conditions? *

Yes
No

Please select any serious medical conditions that apply *

Asthma
Diabetes
Other

Please list other serious 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, where it is impractical to communicate with me, to arrange for medical treatment and/or an ambulance for my child/ward as deemed necessary *

Yes

Indemnity

I agree that:

I will be responsible for any costs incurred on behalf of my child/ward due to a medical emergency, accident or misdemeanor whilst attending Indonesian Hope Youth activities

I accept all reasonably forseeable risks associated with the Indonesian Hope Youth program, including loss or damage to personal property or personal injury sustained by my child/ward

I confirm that this information is correct and understand that failure to disclose changed or new information will be at my own risk

Name of Parent/Guardian *

First

Last

Signature of Parent/Guardian *

Date *