Anglican Diocese of Melbourne

Details, Driving, Medical Information & Consent Form (U18)

To be completed by the Parent or Guardian of the Applicant
Use the highlight function to select the appropriate options on this form

1. Applicant’s Details

Full Name

Emergency Contact Details

Name

Relationship to Participant

Street Address Postcode

Suburb

Contact Number(s)

2. Media and Driving Consent

Holy Trinity has a policy that a minor cannot travel as a passenger in the car of a P plate driver who has had
their license for less than one year. However, after this one year period your child is allowed to drive with a P
plate driver with your permission. This policy is enforced to increase the safey of the youth as they travel to
and from youth events and camps. The following drivers are P plate drivers who have had 1 or more years of
driving experience. Please indicate if you are happy for your child to drive with the following drivers:
Esther Mathew YES ΝΟ
We also request your permission for your child to be driven by full licensed drivers within the youth leadership
team. Please indicate if you are happy for your child with the following drivers:
Chris Bowditch YES ΝΟ
Ryan Walker YES ΝΟ
Michael Daniels YES ΝΟ
Ellisa Bowditch  YES ΝΟ
Alex Tulloh YES ΝΟ
Marcus Yong YES ΝΟ
During different programs throughout the year (including camp) a number of photographs as well as video
footage may be taken of the youth for the church's records and and for promotion of the Youth Ministry. Please
indicate whether you are willing to allow your child to be part of these photographs or videos.
Photographs YES ΝΟ
Video Footage YES ΝΟ

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 Anglican Diocese of Melbourne
Details, Driving, Medical Information & Consent Form (U18)

3. Medical Information

Doctor/ Health Contact
Name of Family Doctor/Clinic
Phone
Street Address
Suburb Postcode
Medicare Number
Health Care Card Number
Private Medical/Hospital Fund
Membership Number
Ambulance Membership Yes / No
Membership Number
Please highlight if the applicant  Diabetes  Fits of any type  ADHD
..Dizzy Spells  Blackouts  Asthma
suffers from any of the following
 Travel sickness  Heart Condition  Migraines
and provide further details where  Epilepsy  Bed Wetting  Sleep Walking
appropriate  Other:

If you answer YES to any of the following questions please provide details needed.
Does the participant have any known allergies, including drug or food allergies? Yes/No

Has the participant had any recent illness or surgery? Yes/No

Will the participant have any medication? (tablets, injections, dosage) Yes/No
If YES, Who is to administer the medication? Leader / Child / Other?

Does the participant have any special food or dietary requirements? Yes/No

Date of last tetanus immunisation / /

Any further information that the leadership needs to know about your child/ward?

Names and Contact Details of people allowed to collect my child/ward:

4. Consent Form – TO BE FILLED OUT BY PARENT / GUARDIAN

I consent to my child/ward participating in the activities I have received notification of. I will encourage my child/ward to participate and co-
operate with the leaders and other participants. I agree to my child/ward participating in activities outside and/or offsite. I agree my
child/ward to be transported in private cars arranged by the leaders of the event. I authorise the leader/s in charge of any activity
conducted by The Anglican Diocese of Melbourne, to consent on my behalf, where it is impractical to communicate with me to receive
medical or surgical treatment as may be deemed necessary. I am also responsible for the cost of any medical treatment deemed
necessary. I give permission for my child/ward to be administered paracetamol. I understand there will/may be photographs and or video
footage of my child/ward during this activity and am willing for them to be so filmed in appropriate settings. I am also willing for these
photos or footage to be used to promote the ministry in a way that does not identify their name or details.

Print Name Parent Guardian

Signature
Date Signed: / /

Privacy Statement

The Anglican Diocese of Melbourne will only collect information about you that is necessary for the purpose of the event. This includes health and lifestyle information. (only if this is the
case as stated above). If the information is not complete or accurate we may not be able to provide you with the necessary services. Access to this personal information is always
restricted to those staff members that require the information to provide a service to you. In providing services to you, The Anglican Diocese of Melbourne may need to disclose your
personal information, in case of an emergency, to other parties such as medical providers. You are entitled to access information we have on you.

Office use only

Recieved: / /
Entered: / / BY:
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