Child Information Child Details First Name* Middle Name Last Name* Gender*MaleFemale Date of Birth* Place of Birth CRN Address* Suburb* State* VIC NSW SA QLD WA ACT ZIP* School* Parent 1 Parent 1 First Name* Middle Name Last Name* Gender*MaleFemale Address*Same address as child Suburb* State* Postcode* Home Phone* Work Phone* Mobile* Email* Preferred Method of Contact*Home PhoneWork PhoneMobileEmail Is the Natural mother of the child Jewish?*YesNo Are there any conversions in the family? If yes please specify details of the conversions*YesNo Family Status*Both Parents at HomeSole ParentShared CustodyOther Parent 2 Parent 2 First Name Middle Name Last Name GenderMaleFemale Date of Birth Address Suburb State ZIP Home Phone Work Phone Mobile Email Include in email communication Preferred Method of ContactHome PhoneWork PhoneMobileEmail Medical Information Medical Information Medicare Number* Medical Centre Name* Doctor's name* Doctor's Phone* Doctor's Address* Dentist's name Dentist's Phone Ambulance Subscription Authorisation for your child to self-administer medication Has your child been diagnosed at risk of Anaphylaxis?*YesNo Any allergies: eg. food, medication, animals, insects etc?*YesNo Any special dietary requirements?*YesNo Any problems with hearing, sight or speech?*YesNo Any health problems, operations, illnesses, diabilities?*YesNo Does your child take any regular medications?*YesNo Does your child have any physical disability or delay, including intellectual, sensory and physical impairment?*YesNo Emergency/Authorised Contact Emergency/Authorised Contact other than parent. Please include anyone who might collect your child from our centre. Person 1: Name* Relationship to Child* Grandmother Grandfather Stepmother Stepfather Godparent Sister Brother Aunt Uncle Friend Other Address* Suburb* State* VIC NSW SA QLD TAS WA NT ACT ZIP* Home Phone* Work Phone Mobile This person has the authority to: Collect/Deliver your child to/from the service Consent to medical treatment for your child Request/Permit medication to be give to your child If the parent/guardians cannot be contacted, this person should be notified of any accident, injury, trauma or illness involving your child Person 2: Name* Relationship to Child* Grandmother Grandfather Stepmother Stepfather Godparent Sister Brother Aunt Uncle Friend Other Address* Suburb* State* VIC NSW SA QLD TAS WA NT ACT ZIP* Home Phone* Work Phone Mobile This person has the authority to: Collect/Deliver your child to/from the service Consent to medical treatment for your child Request/Permit medication to be give to your child If the parent/guardians cannot be contacted, this person should be notified of any accident, injury, trauma or illness involving your child Person 3: Name* Relationship to Child* Grandmother Grandfather Stepmother Stepfather Godparent Sister Brother Aunt Uncle Friend Other Address* Suburb* State* VIC NSW SA QLD TAS WA NT ACT ZIP* Home Phone* Work Phone Mobile Add another Person Authorisations Authorisations I hereby authorise L'Chaim Chabad-Kingston and Moorabbin Hebrew Congregation staff and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical* I hereby authorise L'Chaim Chabad-Kingston and Moorabbin Hebrew Congregation staff and/or volunteers to photograph my child and use the photographs promotional purposes. (Disclaimer: When photographing large groups of 5 or more children, it may be impossible to exclude your child) Signature Sign on the line with your mouse or fingerReset Signature This page uses 128 bit SSL encryption to keep your data secure.
