Religious Instruction – Enrolment Form 2013
Child’s Details:
Name: ______
Please print Child’s full name that will appear on the certificate when receiving a Sacrament.
Surname last and in capitals
Date of Birth: ______Age: ______Gender: ______Grade in 2013: ______
Main Residential Address: ______
Name of School: ______
Parish: YarravilleKingsvilleBrooklyn
Other Parish (name): ______
Parent/Guardian Details:
Parent/Guardian:Mr/Mrs/Ms First Name ______Surname______
Relationship to the child: (e.g. mother) ______
Address: ______
Contact Nos: (home) ______Work: ______Mobile: ______
Email Address: ______
Child lives with: Both Parents Mother only Father only
Other Please name, e.g. Guardian......
Are there any Court Approved Parenting Plans, Parenting Orders
or any other Specific Issues Orders in place? NO/ YES If yes, please attach copy.
......
Has your child attended Religious Education classes before?Yes / No
If yes, please provide details______
______
Tick the Sacraments the child has already received?
Baptism Reconciliation Eucharist Confirmation
Please attach a copy of your child’s baptism certificate and other sacramental certificates
(if completed) as part of the enrolment form.
When completed, please sign these forms and return to: The Parish Office (located in the Presbytery)
St. Augustine’s Parish Yarraville
Religious Education Program for State School Children
Venue: St. Augustine’s School, Somerville Road, Yarraville. 3013
Tuesdays: 4pm – 5pm
PART A: CONSENT FORM
Child’s full name:
(Surname last and in CAPITALS)
......
Child’s date of birth: ......
Consent to Participate
I …………………………………...... consent to my child ……………………………………...... attending andparticipating in the St. Augustine’s Parish Religious Education Program for State School children in the classrooms of St. Augustine’s School, Somerville Road, Yarraville on Tuesdays from 4pm – 5pm.
In the event that you are unable to communicate with me [or my nominated emergencycontacts], I consent to my child receiving such medical or surgical treatment as may bedeemed necessary and I agree that any such treatment will be at my expense.
I have informed you of any allergies or other medical conditions of my child relevant tothis activity and will make any necessary medication available.
………………………………………………. …………………………………………......
Signature of Parent/Guardian Print name (Surname last and in CAPITALS)
……………………………………………..
Relationship to child
………………………………….
Date
St. Augustine’s Parish Yarraville
Religious Education Program for State School Children
Venue: St. Augustine’s School, Somerville Road, Yarraville. 3013
Tuesdays: 4pm – 5pm
PART B: EMERGENCY CONTACT FORM
Child’s full name: ......
Child’s date of birth: ......
Please provide details for at least one person we can contact
if we are not able to reach you in an emergency.
Emergency contact 1
Name: (Surname last and in CAPITALS)
......
Relationship to child: ......
Address:......
Telephone (home): ......
Telephone (work): ......
Telephone (mobile): ......
Do you give permission for this person to collect your child? ......
Emergency contact 2
Name: (Surname last and in CAPITALS)
......
Relationship to child: ......
Address: ......
Telephone (home): ......
Telephone (work): ......
Telephone (mobile): ......
Do you give permission for this person to collect your child? ......
………………………………………………. …………………………………………......
Signature of Parent/Guardian Print name (Surname last and in CAPITALS)
Relationship to child ……………………...... Date......
St. Augustine’s Parish Yarraville
Religious Education Program for State School Children
Venue: St. Augustine’s School, Somerville Road, Yarraville. 3013
Tuesdays: 4pm – 5pm
PART C: CONFIDENTIAL MEDICAL CONDITIONS FORM
Full name of child: (Surname last and in CAPITALS)
......
Child’s date of birth: ......
Child’s address: ......
Child’s Medicare Number: ......
Do you have Private Health Insurance? ......
If yes, name of fund and policy number:
......
Is the child covered by an Ambulance subscription? ......
If yes, subscription number......
Family doctor’s name......
Family doctor’s address......
Family doctor’s telephone number......
Does your child have any medical conditions which may require special attention? If soplease provide details......
......
Is your child currently taking any medication? If so please provide details includingname of medication, dosage, when and how it is to be taken......
......
Does your child have any allergies? If so please provide details.
......
Does your child have any special dietary needs? If so please provide details......
Is there any other information we should know about your child’s needs?………………………………… ………...... ……......
Signature of Parent/Guardian......
Print name (Surname last and in CAPITALS)......
Relationship to child ……………………….... Date......
St. Augustine’s Parish Yarraville
Religious Education Program for State School Children
Venue: St. Augustine’s School, Somerville Road, Yarraville. 3013
Tuesdays: 4pm – 5pm
PART D: CONSENT TO USE CHILD’S IMAGE
Child’s full name: (surname last and in CAPITALS)
......
Child’s date of birth:......
I …………………………………...... consent to a photograph or video image of my child,……………………………………...... being used without acknowledgement, remuneration orcompensation, in publications
(print, websites, DVDs, CDs ROMs etc) and/orpresentations of the
Catholic Archdiocese of Melbourne and /or St. Augustine’s Parish Yarraville.
……………………………………………….
Signature of Parent/Guardian
......
Print name (Surname last and in CAPITALS)
……………………………………………..
Relationship to child
………………………………….
Date