CKids - Registration Form

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Child's Full Name*

First Name Last Name

Child's Birth Date*

Day Month Year

Child's School*

Child's grade in 2025*

Child's Address*

Street Address
Street Address Line 2
City	State
Post Code	Country

Affiliated Centre*

Parent Information.

Parent 1 Full Name*

First Name Last Name

Parent 1 Phone Number*

Parent 1 Email*

Parent 2 Full Name

First Name Last Name

Parent 2 Phone Number

Parent 2 Email

Child's Medical Information

Allergies*

Medical Conditions*

Medication*

Special Remarks

Child's Medicare Number*

Medicare Number Medicare Reference Number

Medicare Expiry Date*

Private Health Insurance*

Private Health Insurance Number*

Private Health Insurance Expiry*

Child's GP*

GP Phone Number*

Emergency Contacts Other Than Parents.

Emergency Contact #1 - Full Name*

First Name Last Name

Emergency Contact #1 - Relationship*

Emergency Contact #1 - Phone Number*

Emergency Contact #2 - Full Name*

First Name Last Name

Emergency Contact #2 - Relationship*

Emergency Contact #2 - Phone Number*

Authorisation

*

I authorise Yossi Smoller and Reuvi Cooper to act as my authorised nominees. I hereby give any of these nominees consent to sign my child out of CKids, and care for my child from the cessation of the service’s licenced operating hours until the service reopens. I additionally consent for them to authorise medication, medical and dental treatment, hospitalisation, ambulance transport and treatment and excursions on my behalf. I understand that this is a private arrangement. I hereby authorise a CKids staff and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical*

*

I agree that my child is fit to participate and has no medical conditions or injuries that would affect their ability to do so. I confirm that I have disclosed any relevant medical information and accept responsibility for their participation.

I hereby authorise CKids VAC staff and/or volunteers to photograph my child and use the photographs for any CKids VAC for the following purposes:

Yes, Educational PurposesYes, Promotional MaterialsYes, Social Media

If you choose to pay by another method leave the credit card form blank, however your child's place will not be confirmed until your payment has been received.(There is a 2% surcharge for American Express payments.)

Name on Card*

Number on Card*

Card Expiry*

Card CVV*

By clicking submit you are agreeing to all of the policies and conditions outlined above.

CKids - Registration Form

Payment details

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