Youth Group Contact and Permission Form 2021

To be completed for all children under 18 years

Effective from 1st January to 31st December 2021 in relation to the activities indicated in the personal details section below.

Parent/Caregiver 1

Name: *

Contact Number: *

Email Address: *

Home Address: *

Parent/Caregiver 2

Name:

Contact Number:

Email Address:

Home Address:

Emergency Contact (alternate to parent/caregiver)

Name: *

Contact Number: *

Relationship to Child/ren: *

Privacy Declaration

Campbelltown Anglican Churches is exempt from the requirements of the Privacy Act 1988 (Cth) as it is a “small business”. However, we seek to deal carefully with the personal information we collect and to do so in a manner consistent with your reasonable expectations.

The personal information in this form will be made available to –

(a) the youth and children’s leaders involved in the running of the activities in which my child participates, and

(b) medical and emergency services if considered necessary.

Child Personal Details

First Name: *

Last Name: *

Gender: *

Date of Birth: *

Email Address:

Mobile Number:

School: *

School Grade: *

Medicare Number:

Position on Card:

Medicare Expiry Date:

Ambulance Cover:

Yes

Dietary Concerns

Please tell us about any dietary needs your child has that we should know about:

Further Information

Is there anything else you would like us to know?

Thank you for completing this form. If you have any questions or concerns about Friday Night Youth Group please contact

James Massey on 0424 309 004 or the Church Office on 4625 1041.