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Warren Youth Support Group INC

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First name*

Your First name, not the child attending

Last name*

Your Last name, not the child attending

Email*

Phone Number*

Adress*

Childs Name*

Childs Date of Birth*

Does your child have any allergies?*

Yes - List below

If any allergies, please list.

Does your child have any medical conditions or take any regular medications? If yes, please provide details below.*

Does Your child have any special dietary requirements? If yes, please list below*

I agree to my child's photo being published within the organisation, and the Office of Regional Youth, newsletters, social media and for future use?*

Yes

Contact in Case of an Emergency: Name, Phone Number, Relationship to child*

Contact 2 in case of an Emergency: Name, Phone Number, Relationship to child

Medicare Information: Name on Card*

Medicare Card Number:*

Number Position on Medicare Card:*

Medicare Card Expiry:*

I understand that when my child is being transported to and from activities organised by the Warren Youth Group. The driver will have a valid drivers license and ensure the vehicle is appropriately registered and insured, is road worthy, and the number of passengers will not exceed the seat belt provision for the vehicle.*

Agree

Disagree

I understand that bullying, aggression, swearing and violent behavior will not be tolerated, and your child will be sat out of activities if they are not able to follow these rules.*

Agree

Disagree

I understand all reasonable safety precautions will be taken at all times by the organisations involved during the events and activities. All persons involved in my child's care will have current Working With Children Check. I authorize any medical treatment to my child should the need arise in the case of an emergency. I understand the possibility of hazards and risks and agree not to hold the organisations/volunteers and employees liable for damages, losses, or injuries incurred.*

Agree

Disagree

How did you hear about us?

Password*

Confirm password*

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Contact

Emailwarrenyouthgroup@gmail.com