New Enrolment - Girls Brigade (2024) • Emmanuel Uniting Church

Personal Information

Please complete fields as appropriate for girls and adult participants and leaders of Emmanuel (Enoggera) Girls' Brigade for 2024.

First Name *

Middle Name

Last Name *

Preferred Name

Date of Birth (D.O.B) *

Gender *

Primary Phone Number

Secondary Phone Number

Primary Email address *

Home Address *

Home Address Line 2

Home Suburb *

Home State *

Home Postcode *

Medical Information

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

Do you have Dietary Requirements or Food Allergies? *

Details of Dietary Requirements & Food Allergies.

Do you have Anaphylaxis? *

Yes

Do you have Asthma? *

Yes

Details of Anaphylaxis, Asthma, Medical Conditions and other Care Needs (including custody arrangements)

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/your child/ren while at Girls' Brigade 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?

Personal Information

Medical Information

Emergency Contacts

Church attendance

Education and Work Details

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