New Enrolment - Emmanuel Youth Discipleship (2024) • Emmanuel Uniting Church

Personal Information

Please complete fields as appropriate for all adults and children (leaders and participants) who will be attending Emmanuel's Youth Discipleship gatherings for 2024.

First Name *

Middle Name

Last Name *

Preferred Name

Date of Birth (D.O.B) *

Gender *

Primary Phone Number

Secondary Phone Number

Email *

Home Address *

Home Address Line 2

Home Suburb *

Home State

Home Postcode

Medical Information

Please complete fields as appropriate so that we can best care for you /your child/ren while in our care.

Do you have Dietary Requirements, Food or other Allergies? *

Details of Dietary Requirements & Allergies.

Do you have Anaphylaxis? *

Yes

Do you have Asthma? *

Yes

Details of Anaphylaxis, Asthma, Medical Conditions and other Care Needs.

Action Plan for Medical, Behavioral and Special Care Needs

Tip: Please provide clear details to assist leaders and first-aiders in the event of an emergency and to provide best possible care and consideration to your needs in programming.

Medicare Number & Reference

Private Health Insurance

Private Health Insurance Provider

Private Health Insurance Member number

Doctor Name

Doctor Address/Centre

Emergency Contacts

Please list Next of Kin and at least one other person that we can contact should something happen to you while at a youth discipleship gathering or other related events.

Next of Kin First Name *

Next of Kin Last Name *

Next of Kin Relationship *

Next of Kin Phone Number *

Emergency Contact 1 Name *

Emergency Contact 1 Relationship *

Emergency Contact 1 Phone Number *

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Phone Number

Church Attendance

Do you attend a church?

Yes

Sometimes

If so, which Church do you attend?

Education and Work details

Please complete fields as appropriate for adults and children.

Student status

School

School Grade

Higher Education Course

Higher Education Facility

Higher Education Year

Occupation

Workplace