North Shore Presbyterian Church Permission and Medical Form 2021

Which programs will your child attend at North Shore? Please tick appropriate ones.

Programs permission *

Playtime (Thursdays, babies to pre-schoolers)

Sprouts (Sundays, Prep to Year 6)

Child details

First Name *

Last Name *

Gender *

Date of Birth *

School grade in 2021 *

Tip: If not yet in school type 'N/A'

Medical details

Medicare Number (please enter numbers only, no spaces or /) *

Tip: If no medicare number exists, please enter 000 and give a reason in the 'other information' field

Dietary requirements (leave empty if none)

Allergies (leave empty if none)

Medication required during program(s) (leave empty if none)

Other medical/behavioural conditions we need to be aware of

Is there any other information we need to know (e.g. custody order)?

Photos / video

Photos/videos may be taken during the programs by designated team members which could be displayed in a public place (e.g. church publication, presentation, internet site, Facebook page).

Do you give permission for photos and videos to be taken of the attendee?

Other restrictions

Are there any specific activities you do not want the attendee to participate in?

Parent details

Parent/guardian name *

Mobile Number *

Email Address *

Mailing Address *

Mailing Suburb *

Mailing State *

Mailing Post Code *

Emergency contact details

Name of first emergency contact *

Mobile number of first emergency contact *

Name of second emergency contact *

Mobile number of second emergency contact *

Playtime fees

We charge a $20 per family joining fee each year which goes towards our Coordinator's wages. We also charge $5 per week per family which buys resources for the group. You can either pre-pay these via direct debit (details below) or pay cash at Playtime.

Direct debit details:

BSB: 880 117

Account No.: 108 586 322

Account Name: Kristie Tunnah

Please include reference: [Child surname] Playtime

Terms and conditions

I hereby give permission for the personal details given above to be provided to appropriate leaders and/or relevant medical/emergency services personnel as deemed necessary. I understand the details given herein will be used by leaders to contact myself and/or my children and that the details will not be given to any third party, except as provided above. By completing this form, I hereby give permission for my child/ren to attend all scheduled activities, unless I explicitly advise the leadership team otherwise. In doing so I undertake to provide the leaders with any information relevant to the well-being of my child/ren prior to them attending any and all scheduled activities.