KIDZOWN HOLIDAY CLUB 2025 • Helensburgh & Stanwell Park Anglican Church

Number Of Children Attending For 3 Days (Cost Per Child) 0

Child's Details

First Name *

Last Name *

Date of Birth *

School Grade *

Home Address *

Home City *

Parents/Guardian Details

Parents/Guardians First Name *

Parents/Guardians Last Name *

Mobile Number *

Email Address *

Days Attending *

Tuesday 15th April

Wednesday 16th April

Thursday 17th April

Emergency contact details (if parent/guardian cannot be reached)

Name *

Mobile *

Child health information

Child's doctor *

Doctor's address and phone number *

Medicare no *

Card reference no *

Expiry date *

Does your child have any medical conditions we should know about? *

Yes

No

Is the condition Life Threatening or require urgent medical attention?

Yes

No

Describe medical condition and how it may impact your child's involvement:

Does your Child use an Epipen or Asthmatic inhaler?

Yes

No

1. I undertake to promptly notify Helensburgh and Stanwell Park Anglican Church if I become aware of a material change to the

information provided on this form, or of any new information, that may have a bearing on the Churchs capacity to ensure the

safety and wellbeing of my child.

2. I give my permission for the Church staff or leaders to seek information from the doctor named above about how to manage any

allergy or medical condition experienced by my child while under the Churchs care.

3. In the case of a medical emergency, where it is impractical to communicate with me or my emergency contact person, I hereby give

permission to the Church staff and/or leaders, to arrange for my child to receive such first aid, medical or surgical treatment as they

may deem necessary in the circumstances.

Parent or guardian's certifying acceptance of all these conditions *

Accept

I give permission for photo/video to be taken of my child. I understand these images may be used in church publications (eg newsletter, website) without names attached *

Yes

No

Privacy Statement

The safety and wellbeing of your child is important to us. The information contained in this form is collected for the purpose of your childs safe participation in our activities. It will allow us to determine how best to meet your childs health and other needs. Helensburgh and Stanwell Park Anglican Church will treat the information contained in this form confidentially. However it may be shared with the Church staff, the appointed leaders of the actvities in which your child is involved from time to time and with any third party (such as a doctor or other medical professional) where this may be necessary for the safety and wellbeing of your child. If you wish to access this information or have any queries in relation to the manner in which we handle your personal information, please do not hesitate to contact us.

Additional Information

Are there any special dietary requirements for your child?

Are there any people restricted from seeing your child?

Is there anything else we should know about your child that would help us care for them during our program?

Number Of Children Attending For 2 Days (Cost Per Child) 0

Child's Details

First Name *

Last Name *

Date of Birth *

School Grade *

Home Address *

Home City *

Parents/Guardian Details

Parents/Guardians First Name *

Parents/Guardians Last Name *

Mobile Number *

Email Address *

Days Attending *

Tuesday 15th April

Wednesday 16th April

Thursday 17th April

Emergency contact details (if parent/guardian cannot be reached)

Name *

Mobile *

Child health information

Child's doctor *

Doctor's address and phone number *

Medicare no *

Card reference no *

Expiry date *

Does your child have any medical conditions we should know about? *

Yes

No

Is the condition Life Threatening or require urgent medical attention?

Yes

No

Describe medical condition and how it may impact your child's involvement:

Does your Child use an Epipen or Asthmatic inhaler?

Yes

No

1. I undertake to promptly notify Helensburgh and Stanwell Park Anglican Church if I become aware of a material change to the

information provided on this form, or of any new information, that may have a bearing on the Churchs capacity to ensure the

safety and wellbeing of my child.

2. I give my permission for the Church staff or leaders to seek information from the doctor named above about how to manage any

allergy or medical condition experienced by my child while under the Churchs care.

3. In the case of a medical emergency, where it is impractical to communicate with me or my emergency contact person, I hereby give

permission to the Church staff and/or leaders, to arrange for my child to receive such first aid, medical or surgical treatment as they

may deem necessary in the circumstances.

Parent or guardian's certifying acceptance of all these conditions *

Accept

I give permission for photo/video to be taken of my child. I understand these images may be used in church publications (eg newsletter, website) without names attached *

Yes

No

Privacy Statement

The safety and wellbeing of your child is important to us. The information contained in this form is collected for the purpose of your childs safe participation in our activities. It will allow us to determine how best to meet your childs health and other needs. Helensburgh and Stanwell Park Anglican Church will treat the information contained in this form confidentially. However it may be shared with the Church staff, the appointed leaders of the actvities in which your child is involved from time to time and with any third party (such as a doctor or other medical professional) where this may be necessary for the safety and wellbeing of your child. If you wish to access this information or have any queries in relation to the manner in which we handle your personal information, please do not hesitate to contact us.

Additional Information

Are there any special dietary requirements for your child?

Are there any people restricted from seeing your child?

Is there anything else we should know about your child that would help us care for them during our program?

Number Of Children Attending For 1 Day (Cost Per Child) 0

Child's Details

First Name *

Last Name *

Date of Birth *

School Grade *

Home Address *

Home City *

Parents/Guardian Details

Parents/Guardians First Name *

Parents/Guardians Last Name *

Mobile Number *

Email Address *

Days Attending *

Tuesday 15th April

Wednesday 16th April

Thursday 17th April

Emergency contact details (if parent/guardian cannot be reached)

Name *

Mobile *

Child health information

Child's doctor *

Doctor's address and phone number *

Medicare no *

Card reference no *

Expiry date *

Does your child have any medical conditions we should know about? *

Yes

No

Is the condition Life Threatening or require urgent medical attention?

Yes

No

Describe medical condition and how it may impact your child's involvement:

Does your Child use an Epipen or Asthmatic inhaler?

Yes

No

1. I undertake to promptly notify Helensburgh and Stanwell Park Anglican Church if I become aware of a material change to the

information provided on this form, or of any new information, that may have a bearing on the Churchs capacity to ensure the

safety and wellbeing of my child.

2. I give my permission for the Church staff or leaders to seek information from the doctor named above about how to manage any

allergy or medical condition experienced by my child while under the Churchs care.

3. In the case of a medical emergency, where it is impractical to communicate with me or my emergency contact person, I hereby give

permission to the Church staff and/or leaders, to arrange for my child to receive such first aid, medical or surgical treatment as they

may deem necessary in the circumstances.

Parent or guardian's certifying acceptance of all these conditions *

Accept

I give permission for photo/video to be taken of my child. I understand these images may be used in church publications (eg newsletter, website) without names attached *

Yes

No

Privacy Statement

The safety and wellbeing of your child is important to us. The information contained in this form is collected for the purpose of your childs safe participation in our activities. It will allow us to determine how best to meet your childs health and other needs. Helensburgh and Stanwell Park Anglican Church will treat the information contained in this form confidentially. However it may be shared with the Church staff, the appointed leaders of the actvities in which your child is involved from time to time and with any third party (such as a doctor or other medical professional) where this may be necessary for the safety and wellbeing of your child. If you wish to access this information or have any queries in relation to the manner in which we handle your personal information, please do not hesitate to contact us.

Additional Information

Are there any special dietary requirements for your child?

Are there any people restricted from seeing your child?

Is there anything else we should know about your child that would help us care for them during our program?