Child’s name:

Date of birth:

Grade:

School:

Parent / Caregiver full name:

Address:

Relationship:

Home phone:

Work phone:

Mobile phone:

Email:

Emergency contact person:

Relationship to child:

Contact number:

Emergency details:

I / We (parents/guardians names)

give permission for Parish staff, leaders, volunteers and / or carers to administer basic first aid as deemed necessary by aforementioned to this child on my / our behalf in case of medical emergency.

Parents /Guardians signature:

Family Physician Name:

Contact number:

Medicare number:

Name of private health fund:

Year of last tetanus immunisation:

Medical information

Medical conditions:

Medication:

Food or other allergies:

Please indicate any other information that may be helpful for us to know in caring for your child: