Personal and Medical Information • North Pine Baptist Church

Medical & Personal Information Form

CHILD'S DETAILS

First Name *

Last Name *

Preferred Name

Gender *

Date of Birth *

School Grade *

Home Address

Home Address Line 2

Home Suburb

Home Postcode

My child attends the following: *

Playgroup

Kidzone (Sunday mornings during the service)

Junior Youth (Grade 3-6, Fridays)

Unleashed (Grade 7-12, Fridays)

ALLERGIES

Allergies

Tip: Description of Allergy & Medication / Treatment Required

Epipen Required

Where will your Child's Epi-Pen be during program hours?

Please provide a copy of your child's ASCIA Action Plan to the Church Office. office@npbc.org.au

Dietary Requirements

MEDICAL DETAILS

Medicare No.

Reference No.

Are there any conditions or important information that may affect their participation or that we need to know about? eg. asthma, hearing or sight impairment, behavioural issues, formal counselling situations, or any other?

Description of Medical Condition

Medication Details

Description of Other Concerns

PARENT / CARER DETAILS

We are required to have details for 2 parents / carers or trusted contacts who can make decisions in an emergency. These people need to be contactable during youth programs.

The first contact will also be the details we use to send information about future programs via email.

First Parent / Carer or Emergency Contact

First & Last Name *

Relationship (1) *

Contact Number *

Email Address *

Second Parent / Carer or Emergency Contact

First & Last Name *

Relationship (2) *

Contact Number *

Important Information

Custody or Parental Arrangements

Tip: Are there any conditions or circumstances which require special consideration that we should know about? Eg. Custody arrangements?

Permissions

Information Consent - I consent to receiving information regarding upcoming North Pine Baptist Church events. *

Photo Consent - I give permission for photos and video of my child taken at NPBC events to be used for publicity such as church newsletter, church website, church Facebook accounts and other promotional acitvities. *

Livestream Consent -I give permission for my child to be included in live streams published by NPBC (Sunday Services). I am aware the live stream is made available through NPBC church website during and for a limited period time after each event. *

Travel Consent - I consent for my child to travel to offsite events in a leader's car. *

Yes

Terms and Conditions

COMMUNICATION
I consent to receiving information for the program/s in which my child participates. This information will be communicated by the contact details I have provided.
PERSONAL & MEDICAL INFORMATION
I have provided all relevant and vital information personal and or medical that may be of benefit whilst my child/ren attends NPBC events and I understand that it is my responsibility to ensure these details held by NPBC are up to date, including all information required for COVID safe compliance.
RISK & EMERGENCY AUTHORISATION
I am aware, in signing this document, regarding my child/ren participation this program, that certain elements of the program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers may exist in the activities in which my child will be participating. In the event of any emergency, I authorise the leaders to obtain medical advice and/or assistance which they deem necessary. I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.
SIGN IN & OUT.
I am aware my presence (or a delegated adult representative) is required to sign in and out my child/ren out of all programs, unless communicated otherwise by the program. I am aware that at JUNIOR YOUTH grade’s 3-6 child/ren must be signed in and out by a parent / guardian. I am aware that at UNLEASHED grade’s 7-12 child/ren are permitted to sign themselves in and out of UNLEASHED.
PHOTO PERMISSION
We (NPBC staff and volunteers) occasionally will choose to capture some footage and photos at church events on an authorised device. These may be used for publicity such as Church Newsletters, Church Website, Church Facebook & Instagram accounts, and other promotional activities. We respect that some parents / guardians may prefer for their child not to be present within these photos. Please indicate your preference via the medical form consent section.
MOBILE PHONES & OTHER ELECTRONIC DEVICES
We accept that mobile phones and other electronic devices are a normal part of many young peoples’ lives. We expect that all mobile phones and other electronic devices of a young person should be silenced or turned off during children’s and youth programs. We respect program participants privacy by not permitting footage or photos to be captured by non-authorised devices. Each program may implement additional requirements around mobile phone and electronic device use.
BEHAVIOUR
The standard of behaviour expected throughout the program is consistent with what is expected of the child while at school. In extreme cases, following consultation with and the approval of the Ministry Coordinator, the leaders may determine that a student must immediately return home. If serious misbehaviour warrants this action, parents / guardians will be advised immediately of the situation and be required to arrange to bring their child home.

I agree to the above Terms and Conditions *

- Please read with your child -

Do you agree to listen and respect leaders?

Do you agree to interact with others in an encouraging and kind manner?

Do you agree to take care of our resources and space?

Do you agree ot have heaps of fun?

Do you Agree? *

Yes

Signature of Care Giving completing Medical & Personal Information Form *

Date *