Protecting Your Privacy
Protecting your privacy is important to us. The information we seek allows us to manage risk, provide reasonable care and administer your involvement in our program. We are careful
to keep your information confidential, and provide it only to those agents acting on behalf of the organisation who need it to enable them to perform their agreed activities (e.g. the
First-Aider-In-Charge). You are welcome to contact our office in relation to issues regarding your personal information and for a copy of our Privacy Policy. We only ask for information
that is necessary for the purposes outlined in this statement. In some circumstances, if you don't provide us with all requested information, you could miss the opportunity to be
involved in our program.
Participant Contact Details
Given Name
Surname
Preferred Name
Date of Birth
Address
Home Phone
School Year
Male/Female
Suburb
Mobile
State
Postcode
Parents Email
Name of friend you would like to be in the same group as:
Please note - we will make every effort to meet these requests, but depending on numbers and age break groups, it may not be possible to meet every
request.
Safety and Care Details
In case of an emergency, please list phone numbers where a relative or friend of the child may be contacted during the course of the program.
Full Name
Relationship
Phone number (mobile preferred)
1.
2.
3.
Information on Relevant Conditions
Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment, mental health issues, formal counselling
situations, ADHD or any other?
If yes, please give details:
Yes/ No
Program Preparation Details
Does your child have any special dietary requirements?
Does your child have any specific allergies?
Yes/No
Yes/No
If yes, please give details:
If yes, please give details
In attending the program, you consent to your child's participation in a range of general sporting and recreational activities.
Are there any specific activities that you do not wish your child to participate in?
Yes/No
If yes, please give details:
Do you consent to appropriate use by us of photographs taken during the event that include your child?
Yes / No
Medical Information
Medicare No.
No. on Medicare Card
Expiry Date
Do you have ambulance cover? Yes/No
Insurance Provider Membership No. (if applicable)
Health Care Card No. (if applicable)
Will your child need to take any tablets or other medication during the course of the program? Yes/No
If yes, please give details:
Please note that in regards to non-prescription medications such as paracetamol (e.g. Panadol), it is our policy that leader team
members do not provide medications.
Has your child been taken off medication recently?
Yes/No
If yes, please give details
Has your child previously broken/fractured any bones?
Yes/No
If Yes, please give details
What is the year of your child’s last tetanus injection?
Please indicate if your child has or had any of the conditions below.
treatment
Details: e.g. severity,
last injection,
Condition
treatment
Asthma
Fits/Convulsion
Mumps
Appendicitis
Faint/Dizziness
Pneumonia
Bronchitis
Glandular Fever
Tonsillitis
Chicken Pox
Hyperactivity
Allergy – foods
Diabetes
Hypo activity
Allergy – animal
Ear Infections
Heart Problems
Allergy – other
Epilepsy
Measles
Present
Condition
Past
last injection,
Present
Details: e.g. severity,
Past
Present
Past
Condition
Provide additional details if necessary.
Details: e.g. severity,
last injection,
treatment
Participant Behavioural Agreement
By attending Kidzone you agree to:
Do what your leaders instruct you to do and to treat other participants, and their property, with respect:
No putting others down.
Do not touch property that does not belong to you.
No foul or abusive language or behaviour
Do not interfere with equipment or facilities
No racist or sexist language or humour.
I understand that if I fail to fulfil the above requirements that I will be asked to leave and that any costs associated with my departure will be my responsibility or that of my
parent/guardian/care-giver.
Participant Name:
Date:
Participant Signature:
Who will collect your child(ren) at the end of the program? Please nominate either yourself or another trusted adult:
Name:
Relationship To Child:
Your agreement with The Salvation Army
I am aware, in signing this document regarding my child’s participation in this program, that certain elements of the program could
be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers exist in the activities in
which my child will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to
minimise exposure to known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond
the control of the organisation, its leaders and staff. In the event of any emergency where my nominated contact people are
unavailable:
I authorise the leaders to obtain medical advice and/or assistance which they deem necessary.
I further authorise qualified practitioners to administer anaesthetic if required.
I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary.
I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.
I confirm that the information contained in this application is true and correct.
I agree to inform The Salvation Army Oakden of any change to these details.
Date
Parent/Guardians Declaration
Name of parent/caregiver
relationship to child
If other than a parent or guardian, please indicate
Signature of parent/caregiver