Youth Registration 2025 • St Matthias Anglican Church (Plentylife)

This form is intended to assist leaders in case of any medical emergency during the course of participating in any youth ministry activity. Please complete fully and in the presence of a parent/guardian.

Contact info

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

School

School Grade (or equivalent)

Home Address *

Home City *

Home Postcode *

Phone Number *

Email Address *

PARENT/GUARDIAN DETAILS #1 (PRIMARY CONTACT)

Relationship to Child *

Parent Name *

Home address (If different to Child)

Parent Phone Number *

Parent Email

PARENT/GUARDIAN DETAILS #2

Relationship to Child

Parent Name

Home address (If different to Child)

Parent Phone Number

Parent Email

EXTRA EMERGENCY CONTACT DETAILS (if needed)

Emergency Contact Name (If different to parent/guardian)

Emergency Contact Phone Number (If different to parent/guardian)

Relationship to Child

Doctor/Health Contact

This information would only be used in a medical emergency.

Name of Family Doctor

Address of Family Doctor

Phone number of Family Doctor

Medicare Number

Health Care Card Number

Medical/Hospital Fund

Medical/Hospital Fund Membership Number

Are you an ambulance subscriber?

Yes

Ambulance Membership Number

Are there any medical conditions or allergies (including dietary) the leaders need to be aware of? *

Yes

Tip: (e.g. Diabetes; Asthma; ADHD; Epilepsy; Other - please specify)

Please provide details of medical condition or allergy *

Does your child have an asthma management plan? *

Yes

I agree to email a copy of the asthma management plan to admin@plentylife.org.au *

Does your child have an EpiPen and/or anaphylaxis management plan? *

Yes

I agree to email a copy of the anaphylaxis management plan to admin@plentylife.org.au *

I will ensure an EpiPen is brought to all youth events *

Does your child take any medication that it's important we know about? *

Yes

Please include all relevant details. *

PERMISSION

I consent to my child/ward's participation in the activities of the Plentylife Youth program. I will encourage my child to participate and co-operate with the leaders and other participants. In and emergency, I authorise the leader/s in charge of any activity conducted by Plentylife Church to consent on my behalf, where it is impractical to communicate with me, for my child/ward to receive medical treatment as may be deemed necessary. I am also responsible for the cost of any medical treatment deemed necessary. I give permission for my child/ward to be transported in private cars arranged by the leaders as necessary. I understand that children will never be in a vehicle alone with a leader unless additional permission to this form has been received. *

Yes

I give my child/youth permission to be a part of online group activities such as youth bible studies and/or children's activities using social media platforms such as Zoom, Discord, Emails, Facebook, Messaging Services etc. I understand there will always be at least two adults from the recognised church/parish youth/children's ministry in attendance. It is my understanding that there will be no one-on-one online communication in this arrangement. *

Yes

I give consent for photographs and video footage of my child/ward during activities and only in appropriate settings. I give permission for these photos and videos to be used internally within Plentylife. My child/ward is also willing for this to take place. *

Yes

I am also willing for these photos or footage to be used to promote the ministry in a way that does not identify their name or details. I understand that promotional purposes may include the Plentylife website and social media accounts, as well as other Plentylife promotions *

Yes

Names of people allowed to collect my child/ward in the event that I am unable

Contact permission

I do not want to receive sms communications about youth group