CityLight Church

Child's details

First Name

Last Name

Date of Birth

Home Address

City

State

Postal Code

Emergency Contact - Option 1

First Name

Last Name

Relationship to child

Best contact number

Emergency Contact - Option 2

First Name

Last Name

Relationship to child

Best contact number

Medical Information

Do you give permission for medical intervention (including ambulance services) in the case of an emergency, and you cannot be contacted immediately?

Yes

No

Is your child covered by a private medical benefit fund

Yes

No

If yes, the name of the fund.

Medicare number

Child’s Individual Reference Number (IRN)

Health Information

Are there any health conditions CityLight leaders should be aware of regarding the health and well-being for your child (Asthma, allergies, convulsive seizures, diabetes)?

Yes

No

If ‘Yes’ , please indicate

Regular doctor’s name

Contact number

Has your child had a tetanus immunisation?

Yes

No

If ‘Yes’, when?

Is your child allergic to any drug/medicine?

Yes

No

If ‘Yes’, please give details

Are there food allergies which we need to know about?

Yes

No

If ‘Yes’, please give details

Is there any other information you think might be helpful for us to know?

Signature

Kid's Medical Form

Medical Information

Health Information

About

Gatherings

Kid's Medical Form

Medical Information

Health Information

About

Gatherings

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