NorthernLife Kids Holiday Club

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Date: April 17th-19th, 2023

Time: 9am-12:30am
Address: Northern Life Baptist Church, 1 Pretoria Parade, Hornsby NSW 2077

Contact: hamish@northernlife.org.au

Parent/guardian name/s
*

Phone
*

Email *

Address *

Participant’s name *

Date of birth *

YYYY

Dietary issues: Is there anything your child can not eat and/or drink? Yes / No
(If yes, please indicate foods or beverages your child should not consume).
*

Medical conditions: Please list any medical conditions or allergies, and any medication or special care they require.

If your child is anaphylactic to any substance, please provide information regarding EpiPen and management plan.

Participant’s name (2)

Date of birth

YYYY

Dietary issues: Is there anything your child can not eat and/or drink? Yes / No
(If yes, please indicate foods or beverages your child should not consume).

Medical conditions: Please list any medical conditions or allergies, and any medication or special care they require.

If your child is anaphylactic to any substance, please provide information regarding EpiPen and management plan.

Participant's name (3)

Date of birth

YYYY

Dietary issues: Is there anything your child can not eat and/or drink? Yes / No
(If yes, please indicate foods or beverages your child should not consume).

Medical conditions: Please list any medical conditions or allergies, and any medication or special care they require.

If your child is anaphylactic to any substance, please provide information regarding EpiPen and management plan.

What days will your children attend? *

Day 1

Day 2

Day 3

Required

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