Childre's Information *

First Name

Last Name

Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Details *

First Name

Last Name

Parents Date of Birth *

MM

DD

YYYY

Parent's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Authorised Nominee Please list the names of any person at who You authorise to be contacted and / or to collect your child in the event of an emergency where we are unable to contact you or the other primary carer listed in the PARENTS details above. Is authorised to consent to medical treatment of, or to authorise administration of medication to the child Is authorised to authorise an educator to take the child outside of the service premises

First Name

Last Name

Phone

(###)

###

####

RadioChildren's Health Information If any of the following illnesses/conditions/allergies are applicable to your child/children please indicate by selecting the checkbox and providing a brief description of the details below.

Asthma

Epilepsy/Seizures

Downs Syndrome

Diabetes

Socio/Emotional Disorder

Allergies/Risk od Anaphylaxis

Hearing Impairment

Visual Impairment

Aspergers

A.D.D. or A.D.H.D.

Food Sensitivity

Communication Delay

Intellectual Impairment

Behavioural Disorders

Physical Restrictions

Other

None

Medication

Will your child require any medication to be administered by staff during the program?

No

Yes - If yes, you will need to complete an ADMINISTRATION of MEDICINE AUTHORITY FORM.

Does your child/ren have any difficulties or disabilities which may require additional assistance or support in order for them to participate in the program?

Yes

No

Special Considerations

Are there any special considerations for you child. Eg Cultural or religious considerations or dietary requirements.

No

Yes

Access/Custody Information (If Applicable)

RISE requires details of any court orders, parenting orders or parenting plans relating to powers, duties, responsibilities or authorities of any person in relation to the child or access to the child and any orders relating to the child’s residence or the contact with a parent or other person.

First Name

Last Name

Authorisations/Acknowledgments *

Authorisations/Acknowledgments(Required) I agree to the below agreements I agree all details provided are true & correct I authorise RISE to seek information from my child’s school regarding additional information pertaining to their well being and Enrolment I authorise for RISE to collect my child from an agreed bus stop prior to training. I authorise RISE to transport my child to school after training. I authorise RISE to seek medical attention for my child in the event of an accident / emergency from a registered medical practitioner, hospital or ambulance service I authorise RISE to arrange transportation of my child by an ambulance service if required. I have read the medical conditions & communications policy and agree to the conditions set out in these policies. I accept that RISE staff and directors will not be held responsible for any financial responsibilities from injuries sustained by my child / children listed on this form I Authorise for the Wellbeing officer or a director to administer one dose of panadol to my child in the event staff are unable to contact either Parent / Guardian listed on this form I authorise the staff at RISE to take photographs and videos of my child involved in experiences for purposes of promoting the organisation. This involves Accreditation and Displays within the same, and inclusion on our website and company Facebook page. I authorise for my child/children to watch G and PG (parental guidance) rating videos.

Yes, Agree to the above agreements

No, I do not Agree to the Above Agreement

I understand that as a Parent/Guardian that I may have to volunteer in activities that support RISE as an organisation *

I Understand and Agree

Parents Signature *

First Name

Last Name

Date

MM

DD

YYYY