Children's and Youth Indemnity and Permission Form

Program/Group Name: *

Child's Full Name *

Date of Birth *

Emergency Contact Name *

Emergency Contact Mobile Number *

Emergency Contact Relationship *

Please give details of a) any person/s not permitted to contact or collect your child/ren while in the care of the above named group and b) any Court order related to such:

I consent to my child becoming a member of the above program. I will encourage my child to attend and participate regularly and to cooperate with the leaders and other children.

I authorise the leader in charge of the above-mentioned group to arrange for my child to receive such first aid, medical or surgical treatment as the leader may deem necessary at any time during the activities. I further authorise the use of Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgment it is necessary. I accept responsibility for payment of all expenses associated with such treatment.

I agree to indemnify and hold harmless the Donnybrook Community Church, the church, and any individual staff or voluntary leaders against all claims arising out of any injury to the child, and the relevant activity being undertaken unless such injury results from a failure in the duty of care of the Donnybrook Community Church, the church, or any individual staff or voluntary leader.

There may be occasions when it is necessary to transport children or to walk to nearby facilities. This will not occur without seeking my permission, except in the case of an emergency evacuation.

SIGNATURE OF PARENT/GUARDIAN:

Digital Consent Declaration

By entering your full name and the date below, and clicking "Submit", you confirm that you are the parent or legal guardian of the named child. You acknowledge that this submission constitutes your agreement to the terms outlined in this form, and that it is equivalent to providing your signature in person.

You understand that this electronic submission will be treated as a valid and binding form of consent and indemnity by Donnybrook Community Church.

Full name of Signing Parent/Guardian: *

Date *

CONFIDENTIAL MEDICAL REPORT

The information below is requested to assist in case of any illness or accident, and will be held in confidence. This information may be passed on to medical care providers in the event of an emergency. This information will be securely destroyed once it is no longer required or is replaced.

a) Does your child have any medical conditions (for example, asthma, allergies, anaphylaxis)? If yes, please provide details and Action Plan if applicable.

Please note: our policies require us to request a Medical Action Plan for children with specific medical conditions e.g. anaphylaxis, epilepsy. The onus is on the parent/carer to provide the Medical Action Plan when requested, and to enact the plan if and when required, including providing any treatment (e.g. EpiPen).

b) Is your child presently taking medication? If yes, please state the name of the medication, dosage, etc.

c) Medicare number (please provide 9 digit number plus card position number)

Tip: ie. 3597 03945 3

Valid to:

Tip: for 07/2027, enter 1/7/2027

d) Does your child have any additional needs that we should be aware of?

SIGNATURE OF PARENT/GUARDIAN:

Digital Medical Consent Declaration

By entering your full name and the date below, and clicking "Submit", you confirm that the medical information provided is accurate to the best of your knowledge. You acknowledge that you are the parent or legal guardian of the named child and that this submission authorises Donnybrook Community Church and its representatives to use this information for the purpose of providing appropriate care during programs or events.

You understand and agree that this digital submission is equivalent to signing the form in person and constitutes your informed consent to share and use this information as outlined.

Full name of signing parent/guardian

Date

OPTIONAL: MEDIA CONSENT

Use or disclosure INTERNALLY within Donnybrook Community Church

Unless you tell us otherwise below, images of a person/child may be used by Donnybrook Community Church.

in Donnybrook Community Churchs communication, newsletters, and social events.

Use or disclosure EXTERNALLY

Unless you tell us otherwise below, photographs, video or recordings of a person/child may also be used in publications that are accessible to the public, including:

on the Donnybrook Community Church website.
on the Donnybrook Community Church social media accounts

Privacy

Donnybrook Community Church values the privacy of every person.

Donnybrook Community Church understands that individuals/parents and carers have the right to withhold permission for Donnybrook Community Church to use photographs, video or recordings of a person/child.

I have read this form and I give my consent to Donnybrook Community Church using photos, video or recordings of myself/family/child: *

Name of all consenting parties:

Electronic Signature of person completing form: *