Coastlands Kidz *
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Enrolling Children Registration Form

Fields marked * are required.

ENROLLING CHILDREN
First name *
 Last name *
 DOB *
Attending *
Wed.    Thurs
 School *
 Grade *
First name
 Last name
 DOB
Attending
Wed.    Thurs
 School
Grade
First name
 Last name
 DOB
Attending
Wed.    Thurs
 School
Grade
First name
 Last name
 DOB
 
Attending
Wed.    Thurs
 School
Grade
MEDICAL
Does your child have any allergies (food,medication,insect bites etc)?

Yes No
If yes - please provide details
Does your child have any medical conditions or medication

Yes No
If yes - please provide details
Does your child have any special needs or dietary requirements?

Yes No
If yes - please provide details
PARENT/GUARDIAN DETAILS
Full Name *
Address *
Address 2
Suburb/Town *
Postcode/Zip *
Email *
Home Phone *
Work/Mobile
Alternate Emergency Contact Number *
CONSENT
MEDICAL TREATMENT CONSENT: I the parent/guardian wish to enrol the above said child(ren)in the Coastlands Kidz Holiday Program and understand that whilst reasonable care will be taken to ensure the welfare & protection of my child, I release Coastlands International Christian Centre and it’s staff and volunteers from any and all liability for any and every injury, damage or loss that may occur to my child(ren) or their property. In the case of emergency, I hereby give permission for the First- Aid staff to ensure proper treatment for my child(ren). I understand that reasonable effort will be made to contact me before instituting such procedures, however in any event I agree to pay all doctor, ambulance and hospital fee occurred on behalf of my child(ren).
TRANSPORT CONSENT: I the parent/guardian give permission for child(ren) to be safely transported to the local park for any off-site activities.
PARACETAMOL CONSENT: I give permission for the First-Aid staff to administer paracetamol to my child(ren) if deemed necessary by the First-Aid staff.
INVOLVEMENT CONSENT: I the parent/guardian of the said child(ren) consent that he/she may participate in any activities chosen over the course of the Coastlands Kidz Holiday Program, whether it be games, sports, personal development training, etc, and to the fullest extent permissible release Coastlands International Christian Centre and it’s staff and volunteers from all liability in connection with my child(ren)’s participation in the Holiday Program.
I INDEMNIFY Coastlands International Christian Centre and it’s staff and volunteers in respect of all liability incurred in relation to any and every injury, damage & loss sustained by my child(ren) in relation to the Coastlands Kidz Holiday Program.
PHOTO CONSENT: I the parent/guardian of the said child(ren) to be captured in both photographs and video. Coastlands International Christian Centre reserves the right to use this material for promotional purposes.
MAIL OUT: I am happy to be contacted regarding future Coastlands Kidz events

I do not agree or consent with the above details for the children listed on this application. (please contact our office direct as you will not be able to submit this application)

OR

I agree and consent with the above details for the children listed on this application
 
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