Ministry Information Form • Eastwood Community Baptist Church

Program Name

General Information

First Name

Date of Birth

Last Name

Parent/Guardian Name

Phone Number

Email Address

Dietary

Is there anything your child can not eat and/or drink?

(If yes, please indicate foods or beverages your child should not consume.)

Yes

Restrictions

Medical Conditions

Please list any medical conditions or allergies, and any medication or special care they require. If your child is anaphylactic to any substance please provide information regarding EpiPen and management plan

Medical Conditions

In case of Emergency

Contact 1 Name

Phone

Relationship to child

Contact 2 Name

Phone

Relationship to child

I authorise the leader in charge to arrange for my child to receive such first aid and medical treatment as a trained first aid person may deem necessary.

I authorise the use of calling an ambulance in an emergency

I accept responsibility for payment of all expenses associated with such treatment

I permit photos taken of my child to be displayed in church publications, e.g. website, newsletters, brochures, etc.

Transport authority: If I am unable to collect my child at the finishing time they may be transported home from the program with the following people:

Name

Date

Please note: this information will be stored on Elvanto. If you have concerns or wish for extra privacy for your childs details please speak to Rachel Brunton.