(Current 2025) KFC Youth Medical and Permission Form • Kingborough Family Church

KFC Youth Medical & Permission Form

In order to provide the best level of care while your child/ren are under our supervision, we require that you fill out and return the registration form below. The information below will be treated confidentially within our team.

Personal Details

Youth First Name *

Youth Last Name *

Date of Birth: *

Address: *

Suburb: *

Postcode: *

Youth Email:

Youth Mobile:

School Grade:

Parent/Guardian #1

1st Prt / Gdn Name *

1st Prt / Gdn Relationship to child *

1st Prt / Gdn Email Address *

1st Prt / Gdn Mobile *

Parent/Guardian #2

2nd Prt / Gdn Name

2nd Prt / Gdn Relationship to child

2nd Prt / Gdn Email Address

2nd Prt / Gdn Mobile

Is there any custody arrangements with your child? (please provide details):

Emergency Contact (other than parent/guardian listed above)

Please fill out section below, if only 1 parent/guardian listed above.

Emergency Contact Name and Mobile

Permission to Collect

Who will collect your child at the end of the program? Please list anyone who will be collecting your child (including yourself).

Name/Contact Number (Permission to Collect) *

Medical Information

The following information is supplied (in confience) to assist leaders in the event of an incident.

Allergies

Does your child have any allergies? (Please provide a list of allergies and the severity) *

Does your child have an anaphylaxis plan?

YES

If you child has an anaphylaxis plan, please provide us a copy either in person or by emailing us ( youth@kfc.church ). Thank you.

Asthma

Does your child suffer from Asthma? *

YES

Does your child have an asthma action plan?

YES

If you child has an asthma action plan, please provide us a copy either in person or by emailing us ( youth@kfc.church ). Thank you.

Medical Condtions

Does your child suffer from any medical conditions (please detail below)? *

Dietary Conditions

Does your child have any dietary requirement (please detail below)? *

Other Medical Information

Any other medical information we need to be aware of?

Medical Authorisation

Should I/we be unavailable in the case of an emergency involving my/our child. I/We hereby authorise the Leaders to arrange for such Medical or Surgical treatment, and the administration of medication such as analgesics, as may be deemed necessary. I/We indemnify Kingborough Family Church against all cost arising from such action.

Do you agree to the medical authorisation? *

YES

Photo/Video Release

As a Church we would like to publish photos/videos from our nights onto social media and use them to promote.

I give permission for photos/videos of my child to be used for our advert/promotion material or placement on website. *

YES

I give permission to take/use photos/videos of my child for social media. *

YES

Drivers Release

Due to occasionally being off site we will need to transport children to and from the venue, in these events we hire a bus but occasionally we need to transport a small proportion by car. Leaders will always abide by the law and have full licences.

I give permission for a designated youth leader to drive my child to and from an event in a car. *

YES

Communication Release

Do you consent to us contacting your child directly via text message, or phone call to provide updates or information about the youth program or events?

I consent to a designated youth leader contacting my child directly. *

YES

Your Agreement With us

I understand that although the leaders will take all reasonable care to ensure both the comfort and safety of my child, there is still a risk that an accident may occur.

Name *

I agree. *

YES

Date (today) *