Please complete this form in preparation for your child’s first visit to the crèche or Kids Club. For more information, please call 9400 4600. Please complete all required fields! Craigie crèche Kidz Club Please select a program. Parent / Guardian Details First Name(*) Please let us know your name. Last Name(*) Please enter your suburb. Address(*) Please enter your address Post Code(*) Please enter your post code Phone(*) Please enter your phone number. Mobile(*) Please enter your mobile number. Email(*) Please enter your email address Child Details First Name(*) Please enter child's name Last Name(*) Please enter child's name Date of Birth(*) Invalid Input Age(*) Please enter your child's age. School Attending(*) Invalid Input School Year(*) Invalid Input Gender(*) Male Female Invalid Input Medical/Allergy Conditions Does your child have asthma or any allergies/medical conditions?(*) Yes No Invalid Input Please state the severity of the allergy or condition(*) Mild Moderate Severe Epi Pen supplied Please select a severity. Action plan supplied(*) Yes No Invalid Input Please note: An action plan must be provided upon enrolment for children with severe allergies or medical conditions and those requiring medication. Treatment Required/Additional Information(*) Please enter child's medical conditions Would you like to enrol a second child?(*) Yes No Invalid Input Second Child Details First Name(*) Please enter child's name Last Name(*) Please enter child's name Date of Birth(*) Invalid Input Age(*) Please enter your child's age. School Attending(*) Invalid Input School Year(*) Invalid Input Gender(*) Male Female Invalid Input Medical/Allergy Conditions Does your child have asthma or any allergies/medical conditions?(*) Yes No Invalid Input Please state the severity of the allergy or condition(*) Mild Moderate Severe Epi Pen supplied Please select a severity. Action plan supplied(*) Yes No Invalid Input Please note: An action plan must be provided upon enrolment for children with severe allergies or medical conditions and those requiring medication. Treatment Required/Additional Information(*) Please enter child's medical conditions Would you like to enrol a third child?(*) Yes No Invalid Input Third Child Details First Name(*) Please enter child's name Last Name(*) Please enter child's name Date of Birth(*) Invalid Input Age(*) Please enter your child's age. School Attending(*) Invalid Input School Year(*) Invalid Input Gender(*) Male Female Invalid Input Medical/Allergy Conditions Does your child have asthma or any allergies/medical conditions?(*) Yes No Invalid Input Please state the severity of the allergy or condition(*) Mild Moderate Severe Epi Pen supplied Please select a severity. Action plan supplied(*) Yes No Invalid Input Please note: An action plan must be provided upon enrolment for children with severe allergies or medical conditions and those requiring medication. Treatment Required/Additional Information(*) Please enter child's medical conditions Emergency Contact Details First Name(*) Please enter your emergency contact Last Name(*) Please enter your emergency relation Phone(*) Please enter your emergency relation phone number Mobile(*) Please enter your emergency relation mobile number Parent Declaration I have read and understand the conditions of use of the crèche and Kidz Club as outlined in the Crèche information document. Please agree to continue. I consent to the City's use of photos of a child for whom I am legally responsible, taken by authorised City photographers, for display within the Leisure Centres, promotional and related purposes in City publications, online or on the City's social media platforms. I acknowledge that copyright of the photos remains with the City. Please agree to continue. City of Joondalup Leisure Centre staff will make every effort to ensure that the highest standards of care are offered to the children enrolled in each program and agree for my child to participate in all activities offered. Organisers however, will not be liable for loss, damage or injury to property or person, occasioned as a consequence of the enrolment of any child or children in the City of Joondalup Leisure Centres – crèche and Kidz Club program or participation in that program and as a parent you acknowledge the exclusion of liability accordingly. Acknowledge