Schedule 7 - Teenage Participant Form • Tenthill Baptist Church

Teenage Participant Form - Confidential

Dear Parent / Caregiver, to provide the best possible care while your child is with us, please complete the following form.

Personal Details

First Name

Last Name

Preferred Name

Gender

Date of Birth

School Grade

Contact Details

Home Address

Home Address Line 2

Home City

Post Code

Phone Number

Mobile Number

Email Address

Medical Information

Allergies

Tip: (e.g. Bee stings, penicillin, aspirin)

Dietary Requirements

Tip: (e.g. lactose intolerant)

Self-administered medication

Tip: Are there any self-administered medications that may be taken? (e.g. ventolin / salbutamol, insulin)

Other relevant medical information:

Tip: (e.g. asthma, migraines, dizzy spells, A.D.D.)

Date of last tetanus injection?

Tip: What was the year of the you Child’s last tetanus injection

Is Paracetamol allowed to be taken?

Private medical insurance details

Medicare number

Emergency Contact

Please provide contact details should we need to reach you in an emergency.

Emergency Contact Name (1)

Emergency Relation (1)

Tip: The relationship of the person to the child

Emergency Home Phone (1)

Emergency Mobile (1)

Emergency Name (2)

Emergency Relation (2)

Tip: The relationship of the person to the child

Emergency Home Phone (2)

Emergency Mobile (2)

Safety Information

Is there a custody order regarding this child?

Can we contact the child?

Tip: The leaders often appreciate the opportunity to be in contact with the students in this ministry. This allows us to inform of upcoming events and the ongoing communication between the leaders and the student. Do you approve of your child being contacted through email / mobile phone / facebook by the leaders of this ministry?

I/we authorise our child to travel in a car driven by an approved leader or parent

Permission for digital imagery:

Tip: Occasionally the church’s ministry areas take photos and videos for promotion and advertising of church activities of which your child might or could appear. For this your approval is required. If you consent to this, please provide your name and signature below

I/we understand that every effort will be made to provide a safe environment for my/our child to participate in. However, in signing this form I authorise the leaders, in the event of an emergency, to obtain at my/our expense, any medical, ambulance or similar services considered necessary by the leaders.

I/we recognise that being a part of a community involves mutual care and consideration and therefore agree that unacceptable behaviour may result in our/my child being sent home and/or being temporarily or permanently prohibited from attending the student ministry.

Do you agree to the above statement of participation?