Wave Yth U18 Medical Form • Lighthouse Family Church

Wave Yth Medical Form U18

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)

Can your child swim? *

Yes, my child is a confident swimmer

Yes, but not well

In attending the program, you consent to your child's participation in a range of general sporting and recreational activities. If potentially risky activities of a specific nature are included, the team leader will inform you of these. Are there any specific activities you do not want your child to participate in? *

Yes

If yes, please give details.

Is there anything else we should be aware of?

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

Medical Information

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:

Insurance Provider

Medicare Number

Do you have ambulance cover? *

Yes

Membership Number

Member Number ( Select )

Medical Release *

Accepted

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.

Important: Please note that in regards to non-prescription medications such as paracetamol (e.g. Panadol), it is our policy that leaders do not provide medications unless permission is given.

Do you give permission for leaders to provide paracetamol to your child if they deem necessary? *

Yes

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

Yes

If yes, please give details.

Travel Approval

While it is expected that parents coordinate travel arrangements to and from youth, we understand that at times a ride to or from youth may be requested. In such cases Youth Leadership will ensure that there is always at least two people present in the car at all times, and that students are transported in a road worthy vehicle with a responsible adult who holds a current driver’s licence.

I give approval for my son/daughter to drive with a responsible adult *

Yes

Are there any people NOT Authorised to pick up?

Photos and video may be taken of your child during youth activities. If you DO NOT consent to Wave Yth using these pictures for publication on it's Social Media platforms, please indicate below.

We also ask that you inform your child of your decision, should you not give your permission. Thank you. :smiling_face_with_closed_eyes:

Photo/ Video Release

Accepted

Decline

Your agreement with Wave Yth

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: *