z Child/ Young Person Information Form OLD • Mayfield Baptist Church

Child/ Young Person Information Form

Child/ Young Person's First Name *

Child/ Young Person's Last Name *

Date of Birth *

Gender

School Grade

Parent/Carer's Name *

Parent/Carer Phone Number *

Parent/Carer Email Address *

Address

City

State

Postcode

Medical Information

Are there any allergies, dietary requirements, physical needs or medical issues we should be aware of? *

Tip: If yes, please provide further details/action plan.

If you have an action plan for management of anaphylaxis, asthma or any other condition please provide a copy via email to mbc@mayfieldbaptist.com so that leaders can be made aware of it.

Allergies

Dietary Restrictions

Medical issues/physical needs to be aware of

Emergency Contact Information

Alternative contact details in case we are not able to contact you in an emergency (Please inform this person that you have submitted their details)

Name *

Phone *

Relationship to the child/ young person

Thank you for providing this important information. We will store your details in accordance with the Recordkeeping section of our Safe Church Policy which can be found on our website along with our other Policies and Procedures: https://www.mayfieldbaptist.com/forms

Feedback/Suggestions - please use the space below to note any feedback, suggestions, questions or concerns you may have.

Admin Notes:

Tip: History of Information Forms Received

Mobile Number

Primary Email Address

Child/ Young Person Information Form

Medical Information

Emergency Contact Information

Permissions Given