MBC Youth Registration Form Please enable JavaScript in your browser to complete this form.Parent's/Guardian's Information - Step 1 of 4Personal and Medical Information 2023 Personal information collected by us is only used or disclosed for the purpose of conducting Youth Ministries. However, in order to provide a caring and safe environment the information may be used or disclosed to provide emergency health care and recording incidents involving your child. Parent/Guardian 1 *FirstLastMobile *Email *Would you like to register another parent/guardian? *NoYesParent/Guardian 2 *FirstLastMobileEmailAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHow many children are you registering? *1234NextChild 1Name *FirstLastPreferred NameGender *MaleFemaleNon-BinaryDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year Level *Grade 6789101112Allergies(e.g. bee stings, penicillin, aspirin) Anaphylaxis *NoYesSevere Allergic reaction to:Dietary Requirements(e.g. Coeliac, Lactose intolerant)What was the year of your child’s last tetanus injection?Asthma *NoYesIf Asthma, has it required hospitalisation in the past? *NoYesAre there any self-administered mediation that may be taken? *NoYes(e.g. Ventolin/salbutamol, insulin)Please provide instructions on the medication(s) administered.Other relevant medical information? (e.g. migraines, dizzy spells, ADD, ASD) Is Paracetamol allowed to be taken? *YesNoChild 2Name *FirstLastPreferred NameGender *MaleFemaleNon-BinaryDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year Level *Grade 6789101112Allergies(e.g. bee stings, penicillin, aspirin) Anaphylaxis *NoYesSevere Allergic reaction to:Dietary Requirements(e.g. Coeliac, Lactose intolerant)What was the year of your child’s last tetanus injection?Asthma *NoYesIf Asthma, has it required hospitalisation in the past? *NoYesAre there any self-administered mediation that may be taken? *NoYes(e.g. Ventolin/salbutamol, insulin)Please provide instructions on the medication(s) administered.Other relevant medical information? (e.g. migraines, dizzy spells, ADD, ASD) Is Paracetamol allowed to be taken? *YesNoChild 3Name *FirstLastPreferred NameGender *MaleFemaleNon-BinaryDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year Level *Grade 6789101112Allergies(e.g. bee stings, penicillin, aspirin) Anaphylaxis *NoYesSevere Allergic reaction to:Dietary Requirements(e.g. Coeliac, Lactose intolerant)What was the year of your child’s last tetanus injection?Asthma *NoYesIf Asthma, has it required hospitalisation in the past? *NoYesAre there any self-administered mediation that may be taken? *NoYes(e.g. Ventolin/salbutamol, insulin)Please provide instructions on the medication(s) administered.Other relevant medical information? (e.g. migraines, dizzy spells, ADD, ASD) Is Paracetamol allowed to be taken? *YesNoChild 4Name *FirstLastPreferred NameGender *MaleFemaleNon-BinaryDate of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Year Level *Grade 6789101112Allergies(e.g. bee stings, penicillin, aspirin) Anaphylaxis *NoYesSevere Allergic reaction to:Dietary Requirements(e.g. Coeliac, Lactose intolerant)What was the year of your child’s last tetanus injection?Asthma *NoYesIf Asthma, has it required hospitalisation in the past? *NoYesAre there any self-administered mediation that may be taken? *NoYes(e.g. Ventolin/salbutamol, insulin)Please provide instructions on the medication(s) administered.Other relevant medical information? (e.g. migraines, dizzy spells, ADD, ASD) Is Paracetamol allowed to be taken? *YesNoPreviousNextAre you covered by private medical insurance? *NoYesInsurance Provider’s NamePolicy Holder’s NameFirstLastPolicy NumberMedicare NumberPreviousNextDo you approve of your email being used to inform you of upcoming MBC Youth events? *NoYesAlso note that photographs are sometimes taken by leaders of the children attending the functions or parents attending the various activities of MBC Youth. Do you give your permission for a photograph taken of your child during one of the activities to be used for the purpose of promotional activities? For example, newsletters given or emails to other youth at MBC Youth, video presentations etc. used in church. *NoYesNote that any photographs would only be used for the purpose of Mitcham Baptist Church.I understand and give permission that my child may be transported to/from activities by leaders of MBC Youth in private cars, with the understanding that they will be transported by a driver who has a valid licence and insurance and is considered experienced and responsible by the leadership of Mitcham Baptist Church. *NoYesI/we understand that every effort will be made to provide a safe environment for my/our child to participate in. However, in signing this form, I/we authorise the leaders, in the event of an emergency, to obtain at my/our expense, any medical, ambulance or similar services considered necessary by the leaders. Name of Parent or Guardian *Signature *Clear SignatureGDPR Agreement *I consent to having this website securely store my submitted information according to the General Data Protection Regulation. This information will not be shared, sold or made public and is solely used for the purposes of running this ministry. For more information please refer to our privacy policy at MBC Privacy Policy.We appreciate your co-operation in assisting us with these contact details. The information is important so that we can best care for and accommodate your child during our MBC Youth program. Below are our details, so please feel welcome to drop us an email or give us a call should you have any questions or concerns. Thank you for your co-operation Blessings Ps Paul Bremner 0407 140 301 or [email protected] PreviousSubmit Registration
