Blacktown Anglican Kids Club Registration Form • Blacktown Anglican Church

Child Details

First Name *

Tip: Child's Formal First Name

Preferred Name *

Tip: Child's Name as they'd like to be called

Last Name *

Date of Birth *

School Grade *

School

Gender *

Allergies and Intolerances *

Yes (please give more details in box below)

Allergies and Intolerances - Details

Special Needs *

Yes (please give more details in box below)

Special Needs - Details

Family Address

Address *

Suburb *

Postcode *

Home Phone Number

Parents/Carer Name *

Parent/Carer Mobile Number *

Parent/Carer Email Address *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Mobile Number *

Permissions

Medical Permission

I give consent for my child to receive medical aid in the event of any accident or sickness and agree to pay any fees thus incurred. I understand that personal accident insurance is my responsibility, and that Blacktown Anglican Church and its representatives accept no liability for any accidents.

Medical Permission *

Yes

Permission for Photos

I give consent for my child to be photographed or videoed as needed for church promotional purposes

Permission for Photos *

Time Understanding

I understand that Kids Club starts at 4pm and ends at 5:30pm. We appreciate your partnership in keeping to these times for our leaders' sake.

Time Understanding *

Yes

Discipline Understanding

I understand that Kids Club has a "three strikes and you're out" policy. This means that if my child is given three rule reminders in one afternoon, I will be asked to keep my child home from Kids Club for one week. If I want more information about this, I can speak to the team leader or look at the Kids Club Discipline Policy on the website.

Discipline Understanding *

Yes

Signature

Date *

Tip: Please enter today's date

Signature *

Tip: Please write your own full name here