Sacred Heart Cathedral School
Emergency and Permission Form
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Child's Full Name: *
Room Number: *
Address: *
Child's Date of Birth: *
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DD
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Child's Country of Birth (if not in NZ):
Child's Nationality: *
Child's Ethnicity: *
Length of time in NZ (if the child is not born in NZ):
Home Language:
Child's Religion: *
Child's Date of Baptism:
MM
/
DD
/
YYYY
Child's Date of First Holy Communion:
MM
/
DD
/
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Family Doctor's Name: *
Medical Centre: *
Doctor's Contact Number: *
Does your child have an allergy or medical condition that we should be aware of? Please indicate below details of the condition and any medication your child needs to take at school. *
Child's Immunisation: *
Required
Please check the appropriate boxes for your child's immunisation:
Parents/Caregiver's Contact Details:
Mother's Name: *
Address: *
Mother's Mobile Number: *
Work Phone Number:
Home Phone Number:
Mother's Email Address: *
Mother's Country of birth (if not in NZ):
Mother's Nationality:
Mother's Ethnicity:
Father's Name:
Address:
Father's Mobile Number:
Work Phone Number:
Home Phone Number:
Father's Email Address:
Father's Country of birth (if not in NZ):
Father's Nationality:
Father's Ethnicity:
Emergency Contact Details (Other than Parents):
Name: *
Relationship to the child: *
Address: *
Mobile Number: *
Home Phone Number:
Work Phone Number:
Email Address:
In the event of a Civil Emergency, my child will be collected by:
Name: *
Relationship to the child: *
Address: *
Mobile Number: *
After School Care Details:
I would like my child to attend ASC. Please tick which days.
I/We give permission to the following: *
Required
We also note the following:
In the event of serious physical inquiry and we are unable to contact you,  my child will be transported to the appropriate hospital or Thorndon Medical Centre to be treated by a doctor. I will be responsible for the costs incurred.
I also agree for the contact details to be given to Sacred Heart Cathedral School's Parents & Friends Fundrasing Committee and the Parish Office at Sacred Heart Cathedal.
Signed Name and Date: *
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