Child Name *

First Name

Last Name

Child Gender *

Male

Female

Not applicable

Child Date of birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

In case of emergency, please list the phone number of a friend or relative that may be contacted during the program if the Parent/Guardian is unavailable

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Photo Permission *

Do you consent to appropriate use by us of photographs taken during the program that include your child/ren e.g. inclusion on our social media, placement on our website or in a brochure?

Yes

No

Dietry Requirements *

Does your child have any special dietary requirements? (If YES, please list below)

Yes

No

Activity Participation *

In attending the program, you consent to your child's participation in a range of general sporting and recreational activities. If there is a potentially risky activity you will be notified by the Team Leader. Are there any activates you DO NOT wish your child to participate in? (If YES, please provide more detail below)

Yes

No

Agreement *

I am aware, in submitting this document regarding my child's participation in this program, that certain elements of the program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers may exist in the activities in which my child will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise exposure of known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the organisation, its leaders and staff. In the event of any emergency where my nominated people are unavailable: 1: I authorise the leaders to obtain medical advice and/or assistance which they deem necessary. 2: I further authorise qualified practitioners to administer anaesthetic if required. 3: I accept the responsibility for payment and agree to pay medical, transport and any other related expenses. 4: I confirm that the information contained in this form is true and correct. 5: I agree to inform the leaders of any change to these details.

First Name

Last Name

Submission Date *

MM

DD

YYYY