STUDENT PERSONAL DETAILS
First Name
*
Last Name
*
Home Address
Mobile Number
Date of Birth
*
Email Address
*
PARENT/GUARDIAN DETAILS
First Name
Last Name
*
Address
*
Home Number
Mobile Number
*
Email
*
EMERGENCY CONTACT DETAILS #1
Preferred Name
*
Relationship to Youth
*
Address
Mobile Number
*
EMERGENCY CONTACT DETAILS #2
Preferred Name
*
Relationship to Youth
*
Address
Home Number
Mobile Number
*
MEDICAL DETAILS OF YOUTH
Medicare Number
*
Allergies
*
Does the student suffer from any of the following? (If YES, please give details)
Asthma:
*
YES
NO
Details
Epilepsy
*
YES
NO
Details
Anxiety/Mental Problems?
*
YES
NO
Details
Respiratory Problems
*
YES
NO
Details
Heart Problems
*
YES
NO
Details
Sugar Diabetes
*
YES
NO
Details
Dietary Needs
Please list any other medical conditions we should be aware of
MEDIA CONSENT
I give The Rock Christian Family permission to use photos and video footage of my son or daughter attending Transit Youth for future website and promotional material only.
*
YES
NO
PARENTAL PERMISSION
I/We do hereby give permission for my son/daughter to attend Transit Youth
*
YES
NO
I understand that when my son/daughter leaves Transit Youth, that either myself or a legal guardian assumes the responsibility of signing them out.
I understand that
all volunteer leaders have a current "Working With Minors" Blue Card
Release of Liability -
I/We do hereby release The Rock Christian Family, it's agents, employees and volunteer assistants from any liability whatsoever, not limited to liability arising for negligence and or breach of The Rock Christian Family contract etc arising out of injury, illness, damage, or loss which may be sustained by the said person during the course of involvement with The Rock Christian Family
Consent For Treatment -
I/We hereby authorize The Rock Christian Family to obtain medical attention for my son/daughter in the event of illness or injury. I understand that I am responsible for the costs of such medical expenses as may be necessary. I further authorize the performance of such treatment, anaesthetic, and operations as in the opinion of the attending physician is deemed necessary
This consent form expires January 2024
Parent/Guardian Full Name Giving Permission:
*
Date:
*
Submit
