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Youth Information Form
Name
First name
Last name
Show on directory ?
Please complete this form for your young person if they are under 18 and are attending one of our youth groups
Gender
Male
Female
Youth Contact Information
Address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Show on directory ?
Youth's Email address
Show on directory ?
Home phone
Youth's Cell phone
Show on directory ?
Date of Birth
School/Employment
School
School Year
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Employer
Medical
Allergies
*
Please list all known allergies eg food, insect bites/stings prescription medicines. If there are none please put NONE
Medical Conditions
If your young person suffers from any of these it is helpful for us to know
Asthma
Chronic Nose Bleeds
Deafness
Diabetes
Dizzy Spells
Epilepsy
Fits of any Type
Hay Fever
Migraine
Travel Sickness
Other conditions to be aware of
Is there anything else we need to be aware of
Medications currently being taken
eg inhalers for asthma
What Pain Medications can be given
What medication can we give for pain relief for headaches , bee stings, sprains etc
Antihistamine
Ibuprofen
Inhaler
Paracetamol
Privacy
Permission for use of photos
If you are okay with photos including your young person to be used on social media please select yes
No
Yes
Parent/Caregiver Contact Details
Parent/Caregiver
*
Parent Email
Contact phone number
*
Parent/Caregiver
Email
Parent Cell phone
Emergency Contact
Please advise someone other than yourself who we can contact if we are unable to contact you in an emergency
Emergency Contact
*
Relationship to young person
Emergency Contact Cell Number
*
Emergency Contact Phone Number
Transportation
Sometimes we travel to activities and events. We will endevour to ensure the safety of your young person by checking drivers have the appropiate licenses and that vehicles have current registration and WOF.
I give permission for my child to be transported to and from events/activities
No
Yes
Other
Is there anything else we need to be aware of eg names of people who aren't allowed to pick up your young person
Name of person completing this form
*
Date Completed
Please check the highlighted fields
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