ROAR
Blakehurst Anglican Church
2019 Holiday Club
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Child's First Name *
Child's Last Name *
Gender *
Required
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Suburb *
Postcode *
School *
Current School Year *
Required
What days will your child be attending ROAR? *
Required
Name of Parent/Guardian *
Parent/Guardian Contact No. *
Parent/Guardian Email Address *
Name of Emergency Contact *
Different from Parent/Guardian listed above
Emergency Contact's Relationship to Child *
Emergency Contact No. *
Name of Family Doctor *
Family Doctor's Contact No. *
Medicare No. *
Expiry Date of Medicare No. *
Does your child have any medical conditions? *
Required
If yes, please outline medical condition and medication administered
Does your child have any allergies? *
Required
If yes, please outline allergies, severity, and action plan
Does your child have any special dietary requirements *
Required
If yes, please outline dietary needs
Is there anything else that would be of relevance for us to understand about the learning and care of your child? *
Is there anyone legally restricted from seeing your child *
Required
If yes, please outline details of court order
I give permission for photos and video images of my child to be taken and used by Blakehurst Anglican Church for promotional purposes and presentations. *
Required
I understand my child, accompanied by leaders, may need to traverse between the church premise and Bald Face Public School during the program. *
Required
I understand that I will have to pay the full cost upon arrival on the first day of Holiday Club. *
Required
Parents/Guardians are required to read, and check the yes box below for the following indemnity.  By checking yes in the tick box below I indicate my willingness to permit my child to participate fully in all the activities of Blakehurst Anglican Church Holiday Club, including (but not necessarily limited to) those indicated on the information sheet provided.  In the case of a medical emergency, I hereby give permission for the leader in charge to secure any and all necessary treatment for my child as named.  I agree to pay all such doctor, ambulance and hospital fees incurred on behalf of my child.  I understand that every effort will be made to contact me prior to instituting such procedures.  Whilst every precaution will be taken to ensure the welfare and protection of my child, Blakehurst Anglican Church, its council members, voluntary workers, employees or any other person acting on their behalf are hereby released from any and all liability in the event of an accident or misfortune that may occur to my child or damage or loss of their property. *
Required
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