Kids Club Registration 2026 • Plentylife Anglican Church

This form is intended to assist leaders in case of any medical emergency during the course of participating in any kids ministry activity. Please complete fully.

Contact info

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

School

School Grade (or equivalent)

Home Address *

Home City *

Home Postcode *

PARENT/GUARDIAN DETAILS #1 (PRIMARY CONTACT)

Contact 1 Relationship to child *

Contact 1 Name *

Email Address *

Contact 1 Number *

I give permission for Kids Club representatives to send sms communications about Kids Club to the above phone number

Yes

Home address (If different to Child)

PARENT/GUARDIAN DETAILS #2

Contact 2 Relationship to child

Contact 2 Name

Contact 2 Number

Parent Email

Home address (If different to Child)

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

Medical Information

This information would only be used in a medical emergency.

Medicare Number

Health Care Card Number

Are you an ambulance subscriber?

Yes

Ambulance Membership Number

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

Yes

Please provide details of medical condition or allergy *

Does this person suffer from asthma ? *

Details of asthma and management plan *

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 Kids Club 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. *

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