CHILD'S INFORMATION
First Name
*
Last Name
*
Gender
Male
Female
Date of Birth
*
School
School Grade
-- None --
Pre-Kindy
Kindergarten
Pre-Primary
1
2
3
4
5
6
7
8
9
10
11
12
Dietary Requirements
Nil
Gluten Free
Diabetic
Dairy Free
Tip: Please let team know if you have any other requirements not in this field.
Medical Conditions
PARENT / CARER INFORMATION
Parent / Carer Name
*
Parent/ Carer Phone Number
*
Parent/ Carer Email Address
*
Home Address
Secondary Contact Name
*
Secondary Contact Number
*
CONSENT
I consent for my child to attend SIXOH Youth Activities.
Yes, I give my consent.
I acknowledge that my child will receive first aid or access to emergency services if required.
Yes, I acknowledge
I give consent for photo / videos including my child to be used in SIXOH Youth / Dreambuilders, Bunbury social media, publications and promotion.
Yes
No
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