Youth Indemnity Form 2021

Basic Youth Details

Youth First Name *

Youth Last Name *

Youth Email (Leave Blank If Same As Parent)

Youth Mobile Number (Leave Blank If Same As Parent)

Youth Date of Birth *

Youth Gender

Youth School Year in 2021 *

Parent/Guardian Details

Parent/Guardian #1 Name *

Parent/Guardian #1 Contact Number *

Parent/Guardian #1 Email *

Parent/Guardian #2 Name

Parent/Guardian #2 Contact Number

Parent/Guardian #2 Email

Emergency Contact *

Emergency Contact Number *

Medical/Dietary Information

Please Select Relevant Medical Conditions

Asthma

Allergic to Penicillin

Allergic to Bees/Wasps

Epilepsy

Diabetes

ASD (Autism Spectrum Disorder)

Behavioural Condition (Please Note Below)

Other

Please Select Relevant Dietary Conditions

Vegetarian

Vegan

Allergic to Nuts

Intolerance to Gluten

Coeliac

Allergic/Intolerant to Lactose

Allergic/Intolerant to Dairy

Other

Ambulance Member Number (If Relevant)

Medicare Number (If Relevant)

HealthCare Number (If Relevant)

Private Health Number (If Relevant)

Are there any Conditions/Personal Needs for your child that you would like us to know about?

Regular Medication being taken.

Additional Information

Are there Court-Ordered Custody Agreements in place for this child? *

Yes

Do you give permission for your child to be photographed/recorded during the course of Follow Youth events? *

Yes

Do you give permission for your child's image or video to be used in promotional material for Follow Baptist Church or Follow Youth? *

Yes

Do you give permission for your child to be driven to/from activities by Follow Baptist Church Leaders? *

Yes

Do you give permission for your child to receive food/drink for special events? *

Yes

Form Confirmation

By filling in this form and typing my name below, I signify that I consent my child in participating in the Follow Youth program provided by Follow Baptist Church. I will encourage my child to be respectful and cooperative with all Youth, Leaders and Staff.

Type Name *