LHK Medical Form

Lighthouse Kids Medical and Permissions Form

Protecting Your Privacy

Protecting your privacy is important to us. The information we seek allows us to manage risk, provide reasonable care and administer your involvement in our program. We are careful to keep your information confidential, and provide it only to those agents acting on behalf of the organisation who need it to enable them to perform their agreed activities (e.g. the First-Aid Officer-In-Charge). You are welcome to contact our office in relation to issues regarding your personal information and for a copy of our Privacy Policy. We only ask for information that is necessary for the purposes outlined in this statement. In some circumstances, if you don’t provide us with all requested information, you could miss the opportunity to be involved in our program.

Child Details

First Name *

Preferred Name

Date of Birth *

Mobile Number *

Last Name *

Gender *

School Grade *

Email Address *

Program Preparation Details

Medical Allergies/ Concerns

Medical Allergies/ Concerns ( Further info)

Is there anything else we should be aware of?

Do you have ambulance cover?

Yes

Insurance Provider

Membership Number

Medicare Number

If during an activity, urgent medical attention is required by my child/ Individual and I cannot be contacted, I authorise the relevant leader to take such action as may be necessary and I agree to indemnify Lighthouse Family Church and its leaders from all responsibility relating to the action. An ambulance may be called in the case of a medical emergency, which the parent/caregiver will presume all responsibility for. If an ambulance is called, a parent/caregiver will either travel with the ambulance, or meet the child/young person at the hospital. I understand if I fail to neglect to provide sufficient or current information in writing to enable the proper treatment of my child/ individual, no liability will be accepted for any injuries or illness which he/she may suffer as a result.

Medical release

Accepted

Decline

Safety and Care details

Emergency Contact 1 - Name *

Emergency Contact 1 - Number *

Emergency Contact 2 - Name *

Emergency Contact 2 - Number *

Emergency Contact 1- Relationship *

Emergency Contact 1 - Email

Emergency Contact 2- Relationship *

Emergency Contact 2 - Email

Are there any conditions which require special attention that we should know about, e.g. hearing or sight impairment, ADD or ADHD, behaviour issues, formal counselling situations, or any other? Please list below:

Will your child need to take any tablets or other medication during the course of the program? *

Yes

If yes, please give details.

Are there any people NOT Authorised to pick your child up?

Photos and video may be taken of your child during Light House Kids activities. If you DO NOT consent to Lighthouse Family Church using these pictures for publication on it's Social Media platforms, please indicate below.

Photo/ Video Release

Accepted

Decline

Your agreement with Lighthouse Kids

I am aware, in submitting this document regarding my child’s participation in this program, that certain elements of the program could be physically and emotionally demanding. Furthermore, I understand that certain inherent risks and dangers may exist in the activities in which my child will be participating. I acknowledge that while the organisation and its leaders will make every reasonable effort to minimise exposure to known risks, all hazards and dangers associated with these activities cannot be foreseen or may be beyond the control of the organisation, its leaders and staff. In the event of any emergency where my nominated people are unavailable:

I authorise the leaders to obtain medical advice and/ or assistance where they deem necessary.
I further authorise qualified practitioners to administer anaesthetic if required.
I accept all operation, blood transfusion and/or anaesthetic risks involved in the event that such procedures are deemed necessary.
I accept the responsibility for payment and agree to pay medical, transport and any other related expenses.
I confirm that the information contained in this application is true and correct.
I agree to inform the leader of any change to these details.
I declare that I am the legal guardian of the child named in this form, and have the necessary authority to complete this form.

Name of person submitting the form (if not the child's legal guardian, please forward to the relevant guardian for submission) *

Relationship to child *

Today's Date: *