Blacktown Anglican Kids Registration Form • Blacktown Anglican Church

Child Details

Family Address

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

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 *

Please read this statement carefully:

I give consent for my child to participate in all organised activities, to be photographed or videoed as needed for church promotional purposes, 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. I understand that my child's basic information may be accessed by those in the church community with up-to-date working with children and safe ministry accreditation.

If you have any concerns, please speak to Renee Sheedy (renee@bac.org.au) - the Kids, Youth and Families Minister.

I accept and give consent

Yes

Date *

Tip: Please enter today's date

Signature *

Tip: Please write your own full name here