Youth Group Permission Form. • Camden Anglican Parish

CHILD'S DETAILS

First Name *

Last Name *

Date of Birth *

Gender

School

School Grade *

For the purposes of communicating with you and your child (i.e. change of venue), please include the following details:

Parent's Email

Child's Email (if applicable)

CHILD'S HEALTH INFORMATION

Emergency contact name (If parent can’t be reached)

Phone

Child's allergies and medication taken:

Is your child:

On a special diet, on any medication (not already noted), have a serious illness or disability, have a known behavioural problem or restricted from any activity?

Yes

Please note details below

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

Yes

Please list them below

DETAILS OF PARENT/GUARDIAN

Name *

Street Address

Suburb

Postcode

State

Contact Number *

PERMISSION

I Give permission for my child to participate fully in the Youth Group of St John’s Anglican Church, Camden on Friday nights from 7-9pm in public school terms.

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.

Acknowledgement *

I acknowledge the above statement and agree.

I give permission for photos/videos of my child to be taken that may be used to advertise the group:

Yes