St Andrews Children Forms - ThreeSixTeens • St Andrew's Springfield

Child's First Name *

Child's Last Name *

Parent/ Guardian Email Address *

CONSENT FORM

Privacy discloser: This information is sought by the Parish of Springfield

This information is sought for the primary purpose of providing a safe environment for children with whom the Parish have contact.
This information will be shared with only others significantly involved with child-related activities.
You may seek access to this information if you wish.
This information will be kept for a period of seven years.

Notice for Parents and Participant about the activities

ACTIVITES

Kid's Church (Sundays @ 9:15- 10am, TSAC Senior Campus)

3:16's (Fridays @ 6 - 7:30pm, TSAC Senior Campus)

Off-site activities

Camps

Activity Coordinator

Name: Penny Howchin

Mobile telephone: 0422 220 617

Consent form

As parent/guardian of *

I (parent/ gaurdian name) *

Give my permission for him/her to take part in the activity outlined on this form.

The leaders and instructors have my authority to take whatever action they consider necessary to ensure the safety and wellbeing of the group and/or individuals in the abovementioned activity.

If my child becomes ill or is accidentally injured, the leaders may obtain on my behalf whatever medical treatment is deemed necessary. I will pay all such medical expenses.

I have attached information as requested about my child’s health, including details of his/her limitations for the planned activity. My child’s doctor and/or specialist may be contacted in an emergency.

To the best of my knowledge, this information is accurate and gives details for the treatment of my child.

Signature *

Date *

MEDICAL INFORMATION

Personal information of child

Name *

Gender

Parent/ Guardian Phone Number

Parent/ Guardian Mobile Number *

Date of Birth *

Home Address *

Home Address Line 2

Home City *

Home State *

Home Postcode *

Information of parent/s or carer/s (if parents separated, please include both)

1) Name *

1) Telephone - home

1) Telephone - work

1) Mobile telephone *

1) Email address *

2) Name

2) Telephone - home

2) Telephone - work

2) Mobile telephone

2) E-mail address

Are there any custody/ access matters *

YES

Details

Medicare and health fund details

Medicare Number

Health Fund

Medical information

Anaphylactic *

Allergies *

Asthma *

Seizures *

Bedwetting *

Has child ever been given penicillin *

Was there any adverse reaction *

Is your child currently taking any medication *

Are there any dietary requirements *

Are there any other matters we should be aware of *

Please provide details for all of the fields selected 'YES'

Emergency Contacts

Name & Phone Number *

Family Doctor & Phone number *

Specialist - Name

Telephone number

Parent/ carer signature *

Date *

INDEMNITY FORM

Indemnity

I (name of parent or guardian or self if over 18 years), *

for my child / myself acknowledge and agree that The Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers and contractors will not be liable for any loss or damage to any person or property arising from any act or omission by The Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers and contractors or any participant in the activity whether arising under the law of contract tort or otherwise, and indemnify the said Corporation in relation to any such loss and damage.

I consent to my/my child’s participation in all the activities associated with the program and I hereby authorise and consent to The Corporation of the Synod of the Diocese of Brisbane its employees, agents, officers and contractors obtaining and administering medical assistance, including first aid, paracetamol, transport, blood transfusion and/or anesthetic if required and I agree to indemnify The Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers and contractors for any cost or liability out of the performance of any medical procedure in relation to such medical assistance.

Further I agree to indemnify The Corporation of the Synod of the Diocese of Brisbane, its employees, agents, officers and contractors for any cost or liability arising from any willful damage of any property, and in the instance of bad behavior to either come.

Signature *

Date *

Approval for images

During the activity, St. Andrew's Springfield may be taking photographs and video footage to use to promote future parish events, do you give permission for St. Andrew's Springfield to use photographs and video footage that may involve your son or daughter in such promotions. Please select YES or NO in the field below.

Please select below *

YES

I acknowledge that copies of the photographs and video footage involving my son or daughter can be obtained from St. Andrew's Springfield by making a written request.

I give also my consent to my details being held in the St. Andrew's Springfield database and distributed in the form of an address list to the other campers after the camp.

Participant's agreement

In consideration of being permitted to attend this activity I hereby adopt and agree to be bound by the above conditions, authorities, and indemnities.

Signature *

Date *