Youth Registration Form

Child Info

First Name *

Last Name

Preferred Name

Date of Birth

School Grade

Gender

Special Health Needs/Food Allergies etc., or Medical Action that may be Required:

Any Medication Required During Session? (A parent of guardian must administer any medication):

Special Emotional/Behavioural Needs:

Parent/Guardian Info

First Name *

Surname

Phone Number

Email Address *

Home Address

Home City

Home Postcode

Emergency Contact

Emergency Contact Name and Number, in the event that a parent or guardian is not contactable (Please specify if there are any custody issues or concerns).

Name

Number

Important Info

Periodically, for possible display in Enfield Baptist Church Newsletter or publications, photographs or footage may be taken. Your child’s name will NOT be published or linked with photographs unless permission has been given. Photos may be on display in Kids spaces which are EBC shared spaces during the week.

Do you give permission for your child to be photographed or filmed for promotion of EBC Kids? *

Yes, I give permission

No, I do not give permission

I authorise the Youth Leaders of SOUL FOCUS YOUTH to arrange for my child to receive any first aid and/or medical treatment that the leaders deem necessary. I further authorise the Youth Leaders to arrange for the use of an Ambulance for my child if, in his/her judgment, it is necessary. I understand and accept that it is my responsibility to cover all expenses associated with such medical treatment.

I give my consent for my child to walk and/or be transported (including in private vehicles and by bus) to those locations under the supervision of Soul Focus Youth Leaders. *

Yes

I give permission for my child to be released to walk home etc. *

Yes

Signed

Date