Dominion Youth Registration Form • Shellharbour Community Church

Youth Details

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

School Grade

School

Youth Contact Details

Mobile Number

Email Address

Please send me weekly updates via sms

Yes

Mailing Address

Mailing Address Line 2

Mailing City

Mailing State

Mailing Postcode

Medical Details

Allergies

Dietary Requirements

Does your Youth have

Asthma

Epilepsy

Regular Medication

Special Needs

Parent/Guardian Contact Details

Parent/Guardian 1

Name *

Relationship *

Contact Number *

Would you like updates?

Weekly Texts

Yes

Start of Term Emails

Yes

Parent/Guardian 2

Name

Relationship

Contact Number

Parent/Guardian Authorisation

Medical assistance in case of emergency *

I understand that, in the case of an emergency, the youth leader will endeavour to contact the parent/guardian. If they are unable to contact the parent/guardian, I authorize the youth leader to arrange for my youth to receive basic first aid by a first aid officer and/or in serious cases call an ambulance.

I give my consent for my youth to be captured in both video and photography while they are at Dominion Youth and the right to use this material for social media and other promotions for Dominion Youth, Shellharbour Community Church and its ministries.

Yes

Involvement *

By ticking this box I declare that I am the parent/guardian of the child/ren listed above and I give consent for my child/ren to participate in the activities provided whilst in Dominion Youth.

Signature *

Tip: Please enter your name and email address in order to electronically sign this form.