Indemnity Form (2024) • Wodonga and District Baptist Church

Indemnity & Permission Form

Next Gen Activity *

Child's Details

First Name *

Gender *

Home Address

Home City

Home Postcode

Email Address *

School_attended

I came with a friend from Church

Yes

.

Last Name *

Date of Birth *

Home Address Line 2

Home State

Mobile Number

Phone Number *

School Grade *

Parent / Guardian Details - Emergency Contact Details

Parent's / Guardian's name (#1)

Emergency Name 1 *

Emergency 1 Relationship to Child *

Emergency 1 Address *

Emergency Phone 1 *

Emergency 1 email *

Parent's / Guardian's name (#2)

Emergency Name 2

Emergency 2 Relationship to Child

Emergency 2 Address

Emergency Phone 2

Emergency 2 email

Please give details of,

a) Any person(s) not permitted to contact or Collect your child while in our care

b) Any Court order related to such

Not permitted to contact

Confidential Medical Information

The information below is requested to assist in case of any illness or accident, and will be held in confidence. This information may be passed on to medical care providers in the event of an emergency. This information will be securely destroyed once it is no longer required or is replaced.

Family Doctor

Health Insurance Provider

Dentist

Medicare Number *

Medical conditions

Please list any medication currently being taken

Please detail any Special Needs Requirements

Family Doctor Phone

Health Care Provider Member Number

Dentist Phone

Dietary requirements

Other Medical Conditions

Tetanus immunisation (approx date last injection)

Consent

I consent to my child(ren) becoming a member of the selected groups. I will encourage my child to attend and participate regularly and to cooperate with the leaders and other children.

I authorise the leader in charge of the above mentioned group to arrange for my child to receive such first aid, medical or surgical treatment as the leader may deem necessary at any time during the activities. I further authorise the use of Ambulance and/or anesthetic by a qualified medical practitioner if in his/her judgment it is necessary. I accept responsibility for payment of all expenses associated with such treatment.

I agree to indemnify and hold harmless the Baptist Union of Victoria, the Church and or any individual staff or voluntary leaders against all claims arising out of any injury to the child, and the relevant activity being undertaken unless such injury results from a failure in the duty of care of the Baptist Union of Victoria, the Church, or any individual staff or voluntary leader.

I understand there may be occurrences when it is necessary to transport children or to walk to nearby facilities.

Permission 1 - Outside of normal complex *

I DO

I DO NOT

give permission for my child to participate in activities outside of the normal meeting complex.

Permission 2 - Transport *

I DO

I DO NOT

give permission for my child to be transported in private cars arranged by the leaders of the above named group.

Permission 3 - Photographs / recording *

I DO

I DO NOT

give permission for my child to be photographed &/or recorded during the course of the activity for the purpose of creating promotional material for the Church and it's ministries.

Approval

Submission of this form will constitute your approval and acceptance of the above.

Date Indemnity Form Completed *

Church disclosure and collection statement.

In accordance with the Privacy Policy of the Baptist Union of Victoria and adopted by Wodonga District Baptist Church, any information captured in this form will be used only for the ministry of this church and activities related to this church. The information will not be released to any individual or organisation outside of the church. This information will be stored electronically.