Chindi Kids Holiday Club • Tweed Church of Christ

Participants Name *

Date of Birth *

Participant 2

Date of Birth

Participant 3

Date of Birth

Name of Parent or Guardian *

Address *

Contact Number *

Email Address *

Emergency Contact 1 *

Phone Number *

Emergency Contact 2

Phone Number

Full name of persons permitted to pick-up child *

Are there any medical conditions we should be aware of? (allergy (including food), asthma, medication etc.)

List here

If your child has an allergy or medical condition, please outline the steps needed in order to effectively treat their condition including medication used (epi-pen etc.) or other treatment and contact person and number.

Write here

Acceptance of Risk and Responsibility

I am aware, in signing this document regarding my child/children's participation in Chindi Kids Holiday Club, that while the organisation and its leaders will make every reasonable effort, to minimize exposure to known risks, all hazards and dangers associated with these activities, there is still a risk that an accident may occur.

I acknowledge that by my child participating in the activities at Chindi Kids Holiday Club they may be exposed to risks and dangers, including but not limited to:

Physical or mental injury;

Other participants may act dangerously or with lack of skill;

Property may be damaged, lost or destroyed.

Signature *

Date *