FUSE Participant form

Participant Information

Participants name*

First Last

Date Of Birth*

Parent or Guardian Name*

First Last

Home Phone

Mobile Phone*

Email

Emergency contact information

Emergency Contact*

Yes
No

Will the above parent or guardian be the primary emergency contact

If 'no' please list the emergency contact

First Last

Emergency Contact Phone #

Alternate Emergency contact Name*

First Last

Alternate Emergency Contact Phone*

Medical and Allergy Information

Medical Conditions*

Yes
No

Are there any medical conditions that we should be aware of?

Medical Information

Please list any medical conditions or allergies, and any medication or special care they require

Medical treatment*

Yes
No

I authorise the leader in charge of FUSE to arrange for my child to receive such first aid and medical treatment, as a trained first aid person may deem necessary. This may include the calling of an Ambulance. I accept responsibility for payment of all expenses associated with such treatment.

Dietary Requirements*

Yes
No

Is your child on a restricted diet?

Dietary Requirements

If yes, please detail

Additional information

Off-site Activities*

Yes

I give permission for my child to participate in activities outside of the normal meeting complex - where they are within reasonable walking distance.

Transportation to and from eternal events.*

Yes

I give permission for my child to be transported in private cars arranged by the leaders of the FUSE group. (all transportation will be by full licensed drivers.)

Photos and Media

Yes

I permit photos taken of my child to be displayed on social media or FUSE promotion.

Parent or Guardian Signature*

Name*

First Last

Date*

FUSE Participant Registration

Participant Information

Emergency contact information

Medical and Allergy Information

Additional information