National Head Quarters
49 Capuchins Street
Floriana FRN 1052
MEMBERSHIP – HEALTH – DATA PROTECTION FORM (Under 18’s)
Distrett :District : North - South - Central / Unit:
Sezzjoni :
Section : Dolphin - Brownie - Guide
Ranger - Young Leader / Il-persuna hija membru ĠDID Iva - Le
Is the person a NEW Member? Yes - No
TAQSIMA DWAR IL-MEMBRU/MEMBERS SECTION
Isem / Name : / Kunjom/Surname :Indirizz / Address:
Data tat-twelid :
Date of Birth: / Nru tal-Karta tal-Identita’
ID Card No :
Nru tat-telefon /
Telephone Number: / Nru tal-Mobile /
Mobile Number:
Indirizz Elettroniku /
Email:
PARENTS/GUARDIAN’S SECTION
Mother/Guardian Name & Surname :Isem u Kunjom l-Omm/Kuratur : / Mobile Number :
Numru tal-Mobile :
E-Mail Address :
Indirizz Elettroniku:
Father/Guardian Name & Surname :
Isem u Kunjom l-Missier/Kuratur : / Mobile Number :
Numru tal-Mobile :
E-Mail Address :
Indirizz Elettroniku :
Other Person (Name & Surname)
To be contacted in case of emergency :
Persuna oħra (isem u kunjom)
Li tista’ tiġi kkuntattjata f’każ ta’ emerġenza: / Mobile Number :
Numru tal-Mobile :
INFORMAZZJONI MEDIKA – MEDICAL INFORMATION
It-tifla tbati minn xi kundizzjoni medika jew allerġiji, eż: allerġiji għal xi ikel, li għandhom jiġu infurmati dwarhom il-Guiders responsabbli ?
Does your daughter suffer from any medical conditions or allergies, Eg: food allergies, that the leader in charge should be made aware of?
______
______
It-tifla tuża xi mediċini ? Iva /Le
Does you daughter take any medication? Yes / No
Jekk iva, aghti d-dettalji ta’ x’ tiehu f’liema hin tehodhom?
If yes, give details of type of medication and time to be administered.
______
______
It-tifla ghandha xi bzonnijiet / kundizzjoni partikolari?
Does you daughter have any specific needs /condition (Autism, ADHD, Dyslexia, Epilepsy etc..)
______
______
L-iskola ghandha sapport ta’ LSA? Iva / Le
At school does she have the support of the LSA? Yes/No
Il-ġenituri huma mgħarrfa li jistgħu jintalbu jiġu fuq il-post waqt laqgħat u attivitajiet, biex jiġbru lil uliedhom f’każijiet ta’ emerġenza jew f’każijiet fejn il-Guiders responsabbli jaraw Il-bżonn.
Parents may be called during meetings or activities to collect their children in cases of emergency or other incidents in which the leader in charge deems necessary.
Jien, qed nagħti l-permess lill-Guider responsabbli biex fil-każ li skont hi jkun neċessarju, binti tingħata l-ewwel għajnuna jew trattament mediku urġenti fi kwalunkwe laqgħa jew attività tal-Guides. Jekk l-inċident jew il-marda tkun ta’ theddida għall-ħajja jew hu meħtieġ li jingħata trattament ta' emerġenza, nawtorizza lill-Guider responsabbli biex issejjaħ lil kwalunkwe persunal professjonali tal-emerġenza, jew kollha, biex jassisti, jwassal jew jikkura lil binti u li tagħti permess li jittieħed X-ray, jingħata l-loppju jew id-demm, mediċina jew kwalunkwe trattament ieħor ta' dijanjosi medika jew kura fl-isptar li fil-fehma ta', u taħt is-superviżjoni ġenerali ta', kwalunkwe tabib, kirurgu, dentist, liċenzjat jew persunal professjonali tal-isptar jew mediku ieħor jew ta' istituzzjoni liċenzjata tipprattika fl-Istat li fih ikun se jsir it-trattament. Hu mifhum li l-kura medika għandha tingħata immedjatament u li l-ġenituri jew min għandu l-kura u l-kustodja tat-tfal jiġu mgħarrfa fl-iqsar żmien possibbli.
I give permission for my daughter to be given first aid or urgent medical treatment during any meeting or activity if deemed necessary by the Guider in Charge. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Guider in charge to summon any and all professional emergency personnel to attend, transport or treat my daughter and to issue consent for any X-Ray, anesthetic, blood transfusion, medication or other medical diagnosis treatment or hospital care deemed advisable by,and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medicalprofessional or institution duly licensed to practice in the state in which such treatment is to occur.It is understood that medical care will be secured promptly and that parents or guardians will be notified at the earliest possible opportunity.
IVA/YES LE/NO
NOTA IMPORTANTI : Membri li jbatu minn kundizzjonijiet mediċi bħal ażżma jew allerġiji serji għandhom iġibu l-mediċina magħhom għal kwalunkwe attività/laqgħa u javżaw lill-Guider responsabbli dwar l-użu tal-istess mediċina.
IMPORTANT NOTE : Members suffering with medical conditions such as asthma or severe allergies must bring such medication with her on any Guide activity/meeting and inform the Guider in charge on the consumption of such medicine.
Nikkonferma li binti kapaci tgħum tul ta’ 50 metru mingħajr għajnuna
I confirm that my daughter is able to swim 5 0 metres unaided IVA/YES LE/NO
KUNSENS DWAR PROTEZZJONI U PRIVATEZZA TAD-DATA
DATA PROTECTION FORM
Għall-fini tal-Att dwar il-Protezzjoni u Privatezza tad-Data tal-2001, jien nagħti wkoll il-permess lil Malta Girl Guides biex jieħdu ritratti, videos u pubblikazzjonijiet tal-attività f’liema ritratti/vidjows/pubblikazzjonijiet tista’ tidher binti. Dawn ir-ritratti u vidjows jistgħu jintużaw mill-Assocjazzjoni għal skopijiet interni (eż. logbooks) u pubbliċi (eż. forma ta’ reklamar u fuq il-websajt tal-Malta Girl Guides stess) eċċ.
For the purpose of the Data Protection Act 2001, I am also giving the necessary permission to the Malta Girl Guides to take photos, videos or issue publications of any activity, which photos, videos or publications may show my daughter. These photos or videos may be used by the Association for interal use (such as logbooks) and also public initiatives (such as adverts or on the Malta Girl Guides website) etc.
IVA/YES LE/NO
Firma/Signature:______Ġenitur/Parent/Kuratur/Guardian:______
For Office Use Only:
Payment of €______
Cash/Cheque Cheque No:______