Kids Club – Medical Consent Form

St. Luke's Vermont

 

      St L20140713-192434-69874569.jpguke’s Anglican Church

Children’s & Youth Ministry

Medical Information / Consent Form

This form is intended to assist leaders in case of any medical emergency during the course of participation in any children’s or youth ministry activity.

 

This form is to be filled out by the parent/guardian of the participant

Please complete fully and return to a leader as soon as possible.

 

Parent/Guardian: (please circle)

Name:.………………………………………………………………………………………………………..

Phone: …………………………….………… Mobile: …………………………………………………….

Address: …………………………………………………………………………………………………….. …………………………………………………………………………………………………………………

Postcode: ………………email: ……………………………………………………………………………

 

Participant (Child):

Name…………………………………………………………………………………………………………

Address:…………………………………………………………………………………………………..…………………………………………………………………………………………………………………..

Postcode: ………………………………..

Date of Birth:……………………………… School ……………………………………grade…………….

 

Emergency Contact:

Name:…………………………………………………………………………………………………………

Relationship to Participant (Child): ……………………………………………………………………….

Address:………………………………………………………………………………………………….…..…………………………………………………………………………………………………………………

Postcode: ……………….email: …………………………………………. ……………………………….

Phone:…………………………………… Mobile: ………………………………………………… ………

 

Doctor/ Health Contact

Name of Family Doctor: ………………………………………………Phone: …………………… ……..

Address:………………………………………………………………………………………………………

…………………………………………………………………………………………………………………. Postcode: ……………………………

Medicare No:…………………………………………… Health Care Card No: …….……………………

Medical/Hospital Fund: ……………………………………………………………………………………. Membership No: ……………………………………………………………………………………………

 

 

 

 

 

 

Medical Information / Consent Form continued

 

Name of Child………………………………………………
Are you an ambulance subscriber? Yes/No Membership No: ………………………………………..
Medical conditions the leaders need to be aware of

e.g. ? diabetes;  ? asthma;  ? ADHD;  ? Travel sickness;  ? Epilepsy;  ? Allergies, ? Other – please specify ………………………………………………………………………………………………………………………………………………………………………………….. ……………………………………………….

………………………………………………………………………………………………………………………………………………………………………………….. …………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

.

(Please discuss any special concerns or action plan to be followed in an emergency, with a leader at the time of registration.)

 

Will the participant have any medication? Yes/No

If yes please attach details (tablets, injections, dosage)  …………………………………………………………………………………………………………….…………………………………………………………………….. …………………………………….

Who is to administer the medication? Child, leader, other (please specify) …………………………………………. ………………………………………………………………..

Does the participant have any special food requirements? (Food and drink may be used in any of our programs for children from time to time). Yes/No

If yes please give details ………………………………………………………………………………. …………………………………………………………………………………………………………….…………………………………………………………………………….……………………………………………………………………………………………………………………………………………. …….

Further comment: …………………………………………………………………………………………………………….…………………………………………………………………………………………………………….

Date of last tetanus immunisation: …………/…………/…………

Privacy Statement:

Information collected is handled in accordance with the SLV Privacy Policy available at

www.stlukesvermont.org.au, or from St Luke’s Anglican Church office.

 

 

 

 

 

 

Medical Information / Consent Form continued

 

Name of child………………………………………………
Permission:
My child usually attends (please tick)
o   The Lighthouse

 

o   Kid’s Club
I consent to my child’s participation in the activities of which I have received notification. I will encourage my child to participate and co-operate with the leaders and other participants.

 

I do/do not give permission for my child to participate in activities off site. (Please indicate)

 

I do/do not give permission for my child to be transported in private cars arranged by the leaders of the above named group. (Please indicate)
I authorise the leaders in charge of any activity conducted by St Luke’s Anglican Church in

Vermont, to consent on my behalf, where it is impractical to communicate with me, for my

child to receive medical or surgical treatment as may be deemed necessary. I am also responsible for the cost of any medical treatment deemed necessary.
I understand there may be photographs and/or video footage of my child during this activity and am willing for my child to be so filmed in appropriate settings. 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 and are not published on a website or distributed in an electronic format. My child is also willing for this to take place.
Names of people I authorise to collect my child in the event that I am unable to:

………………………………………………………………………………………………………………. ……………………………………………………………………………………….. …………………….

……………………………………………………………………………………………………………… ………………………………………………………………………………………………………………

(If a person other than the parent or authorised persons named above is to collect the child on a

particular day, permission must be given in person to the leader by the parent on the day.)

 

Signed: ………………………………………………………… Date: …………/…………/…………

(Parent/Guardian)

Always write in ink; sign and date documentation including alteration; do not use correction fluid to alter any documentation but draw a line through the incorrect area; initial and date alterations made.

 

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