Youth Week Registration Form

Registration form

Hervey Bay Presbyterian Church – Youth Week Program

17  –  20 January 2017

(A form is needed for each child)


Name of Parent/Caregiver: _______________________________________________________


Contact details: Phone: ___________________ Mobile:  _____________________


Address: _______________________________________________


Doctor:  ___________________ Phone:  _____________________


Name of child: _______________________________________________________


Special needs: Allergies:  ______________________________________________


Medical condition/s: _____________________________________


Physical Restrictions: _____________________________________


I (parent/caregiver) _______________________________________  hereby give permission for my child (name above) to attend the Youth Activity Program of the Hervey Bay Presbyterian Church.  I understand that adult supervision will be provided and that all activities will be conducted in accordance with the Child Safe Protocols of the Presbyterian Church of Queensland (as outlined at


Signed: _________________________________ Date:  _____________________________


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