Youth Club Application Form
Heathgrove's Club for girls include extracurricular activities for school-age girls from Year 3 to Year 8. These programs are run by volunteers (university students and young professional women) who also serve as role models and mentors. All activities are "Technology free". We would prefer for all girls not to bring any form of technology (mobiles, iPod, iPad, etc) to the club.

Students in years 9 to 12 may register using this form however technology is used as needed and as long as it is not an obstacle to the normal running of activities.
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Email *
Daughter Name and Surname *
Home Address
Date of birth *
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School Year (2024)
School Name 
Religion/ Belief
Please provide Medicare Number *
Child Name of Medicare Card *
Medicare Reference Number *
Do you have Private Health Insurance? *
Do you have ambulance cover?
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Please provide Health Insurance Provider Name and Insurance Reference Number (if applicable)
Usual GP name and phone number
Is your child in good health? *
Has your child had any major surgery? If so, please specify.

Does your child have any disability?

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If you answered yes to above please outline the nature of your child’s disability.

Does your child suffer from any chronic injury or illness?

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If you answered yes to above please outline the nature of your child’s illness or injury.

Does your child have any allergies? (e.g. drugs, food, plants) Including anaphylaxis?

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If you answered yes to above please outline the nature of your child’s  allergies.

Does your child require regular medication?

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If you answered yes to above please provide the names, dose and times of administration for this medicine.

Is your child’s immunisation up to date including tetanus?

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In relation to swimming activities (including canoeing/kayaking), my child is:

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Please provide details of any dietary requirements.

Do you consent for our staff to administer Paracetamol if it is required?

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Is there any other medical information that may be necessary?

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