Lighthouse Youth Rego • Lighthouse Church

Youth's Details

First Name *

Last Name *

Date of Birth *

Gender *

Youth's Mobile Number

School *

School Grade *

Invited by *

What church do you regularly attend? *

Other

Parent/Carer Contact Details

Parent/Carer Full Name *

Mobile Number *

Email Address

Home Address *

Home City *

Home Post Code *

Parent/Carer #2 Contact Details

Parent/Carer #2 Full Name

Mobile Number

Email Address

Health Information

Describe any allergies in full. eg food, environmental (if none, please write NIL) *

If your child has an EPIPEN, please notify leaders and provide a copy of their Anaphylaxis Action Plan to be kept on file

Is there anything that would be helpful for us to know in caring for your child? (e.g. dasability, behavioural) If none, please type NIL. *

Consent Information

Occasionally photos and videos may be taken during Lighthouse Youth for the purpose of advertising. If you do not consent for your child to be photographed or videoed, please write 'no photos' below. If you are okay with them be occasionally photographed/videoed just leave this blank.

In case of medical emergency, I hereby give permission to the doctor chosen by the church authorities or other persons supervising or administering the children's activity, to ensure proper treatment for/and/or hospitalisation, injection, anesthetic or surgery for my child as named. I understand that every effort will be made to contact me prior to instituting such procedures. *

Yes

I give permission for my child to attend other informal gatherings outside of the usual Friday night youth group time with Lighthouse Youth Group leaders and other youth, with the understanding that there will be at least two youth present or they are in a public place eg. shopping centres, cafes. *

Yes