Blast 4 Kids Rego Form

Please complete this form including the medical information.

Erina Community Baptist Church respects the privacy of all individuals and information provided to us. The purpose of collecting this information is to enable us to contact you in the event of an emergency and so that we can better care for your child/ren. We will not disclose our personal information to any person or organisation outside Erina Community
Baptist Church.

Child's Name: Age: School Yr:
Child's Name: Age: School Yr:
Child's Name: Age: School Yr:
Child's Name: Age: School Yr:

Address (required):

Phone:
School:

Do you attend a church:  Yes No
Days attending (required):  Monday Tuesday Wednesday Thursday Friday

Emergency Contact Details

Name (required)

Email

Address (required)

Phone and/or Mobile

Relationship to child/ren (required)

Medical Information

I wish to declare that my child/ren suffers from the under mentioned medical condition/s or disability/ies and therefore must receive special attention:

  • in the event of an accident:
  • under normal circumstances

Full details must be disclosed:

Medication (dosage and frequency)

Special dietary needs (morning tea will be provided each day)

In the unlikely event that your child/ren need medical treatment please supply their medicare number (required):