LIFEPOINTE YOUTH

Child's Name

First Name

Last Name

Gender

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you consent to appropriate use by us of photographs taken on the program that include your child e.g. inclusion in our newspaper, placement on our web page or in a brochure?

Yes

No

Does your child have any special dietary requirements?

Yes

No

Can your child swim?

Yes

No

Do you have ambulance cover?

Yes

No

Will your child need to take any tablets or other medication during the course of the program?

Yes

No

Has your child been taken off medication recently?

Yes

No

Has your child previously broken/fractured any bones?

Yes

No

Are there any specific activities that you do not wish your child to participate in?

Yes

No

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)?

In the past

Present

Name of Caregiver

First Name

Last Name