Kids Holiday Program Tuesday, 24 September 2019 9:00 am 09:00 Friday, 27 September 2019 2:00 pm 14:00 Lifepointe Baptist Church 186 Wises Road Buderim, QLD, 4556 Australia (map) Google Calendar ICS CLICK HERE TO REGISTER FOR THE KIDS HOLIDAY PROGRAM Kids Holiday Program One form must be completed per child Childs Name * Childs Name First Name Last Name Parent/Guardian Name * Parent/Guardian Name First Name Last Name Phone Number * Parent/Guardian Email * Gender * Male Female Grade * 1 2 3 4 5 6 Does your child have any dietary requirements? * Yes No If yes, please give details Do you give permission for your child to participate in our crazy hair day on the Friday of the program? * Yes No Do you consent to appropriate use by us of photographs taken on the program that include your child e.g. Inclusion in our website, bulletin, etc. * Yes No Are there any custody details we should be aware of? * Yes No If yes, please give details Whilst I acknowledge that every precaution for the safety of my children will be taken, in the event of an incident, I give my full consent for the leaders of this program to administer any First Aid to my child as deemed necessary for the First Aid attendees. Should greater care be necessary an Ambulance will be called * Yes No In case of an emergency, please list THREE phone numbers where you and a friend or relative may be contacted during the course of the program. (please include, "NAME", "RELATIONSHIP", "PHONE NUMBER") * Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment, ADD or ADHD, behaviour issues, formal counselling situations, or any other? * Yes No If yes, please give details Medicare Number * Number of people on Medicare Card * Medicare Card Expiry Date * Will your child need to take any tablets or other medication during the course of the program? * Yes No If yes, please give details What is the year of your child’s last tetanus injection? * Are there any specific activities that you do not wish your child to participate in? Has your child suffered from any conditions in the past or the present that we should be aware of (including asthma, bronchitis, diabetes, ear infections, epilepsy, fits/convulsions, fainting/dizziness, glandular fever, hyperactivity, heart problems, measles, mumps, pneumonia, tonsillitis, allergies)? * Yes No If yes, please give details Do you give permission for your child to attend our excursion to Wildlife HQ on Thursday 26th September? * Yes No Do you give permission for your child to ride on a charted bus to Wildlife HQ? * Yes No Do you have any questions? By completing this form you agree that should your child be found to be extremely disruptive to the program, you will be contacted and be required to collect the child ASAP Thank you for registering for this years Kids Holiday Program. We will be in contact with you shortly.