Thursday Children's Ministry Enrolment Form

Details of Child

Please fill in the form for the child attending a Children's Ministry at St Luke's.

First Name *

Last Name *

Gender *

Date of Birth *

School Grade *

School

Home Address *

Suburb *

Post Code *

Food Allergies *

None

Nuts

Coeliac

Gluten Intollerance

Wheat Intollerance

Lactose Intollerance

Dairy

Eggs

Fish

Shell Fish

Coconut

Salicylates

Amines

Dust Mites

Asthma

Penicillin

Insect Bites

Bandaids

Bee stings

Grass

Hayfever

Other

Other Allergies *

None

Penicillin

Asthma

Dust Mites

Insect Bites

Bee Stings

Grass

Hay Fever

Bandaids

Other

Carries Epipen *

Yes

Carries Ventolin *

Yes

Other Health Notes

Tip: Is there anything that would be helpful for us to know in caring for your child? (Impairments, behavioural issues etc.).

Is there anyone legally restricted from seeing the child? *

Yes

If so, who?

Children's Group *

Sprouts (Kindergarten-Year 2)

Rise Kids (Year 3-6)

Tip: Please select the group that your child plans to come to

Details of Parent/Guardian

Please fill your details here

Parent/Guardian Name *

Parent/Guardian phone number: *

Email Address

Emergency Contact Details *

Tip: Name, relationship to child and contact number for the emergency contact if parent/guardian cannot be contacted

Participation *

Yes

Tip: Ticking the checkbox indicates my willingness to permit my child or children to participate fully in the kids programs within the parish church of St Luke's Miranda.

Emergency Action *

Yes

Tip: In case of medical emergency I herby give permission to the doctor chosen by the church authorities, or other persons supervising or administering the kids activity to secure proper treatment for and/or order hospitalisation or treatment.