Kids/Youth Medical Consent Form • Church@Gabba

Child's Details

First Name *

Last Name *

Phone Number *

Gender *

Date of Birth *

School Grade *

Home Address *

Home Postcode *

Permissions & Medical Details

Do you consent for your child's photo to be taken? May be used for website, social media, advertising, etc. *

Does your child have any medical conditions, special needs or allergies? Please list.

Is there any other information we need to know to care for your child?

Tip: Example - Custody Orders

Parent / Carers Details

We are required to have details for 2 parents/carers or trusted contacts who can make decisions in an emergency. These people need to be contactable during ministries. The first contact will also be sent information about future ministries via email.

First Parent/Carer Or Emergency Contact

Name *

Contact Number *

Email *

Relationship To Child *

Second Parent/Carer Or Emergency Contact

Name *

Contact Number *

Email *

Relationship To Child *

I declare that the information provided above is true and correct. In consideration of the facilities provided by you for our child, I hereby absolutely release and discharge the Church At The Gabba and its employees, agents and volunteers from and against all claims whatsoever arising out of death, personal injury, or loss of or damage to personal property that we or the child may suffer or sustain in the course of their involvement in programs at Church At The Gabba and we hereby indemnify and agree to keep indemnified the Church At The Gabba and its employees, agents and volunteers against all claims whatsoever by us or the child or by any person claiming through us or through the child on our behalf or on the behalf of the child in any way arising, and this discharge may be pleased in bar to any such claim.

Provided that the above does not apply to any claim or any claim to the extent that the Church At The Gabba is indemnified by a policy of insurance issued by a solvent insurer and we further agree that in the event of injury to our child, you are authorised by us to obtain at our expense any medical, ambulance or like services which you in your absolute discretion think necessary or desirable.

Do you agree? *

Yes