Heroes Academy Mega Play Date Application Form - Bunbury • The Pulse

Heroes Academy Application Form - Bunbury

Parent/Guardian Details

First Name *

Last Name *

Home Address *

Phone Number *

Email Address *

Relationship to child *

Child

Application does not guarantee admission to Heroes Academy due to limited spaces and needs assessment. After you have submitted an application form someone from our team will contact you with further information.

Full Name *

Gender *

Date of Birth *

What school do they attend? *

How did you hear about Heroes Academy? *

Medicare Number *

Diagnoses *

Building Your Child's Profile

Our goal at each Heroes Academy event is to make your childs day as successful and fun as possible. One of the ways we do this is to match each child with a volunteer that will best understand and meet the childs needs and interests.

By providing us with as much information as possible, well be best placed to achieve this goal.

Communication

Communication Aids:

Receptive

Select all that apply *

Any additional comments

Mobility

Select one that applies *

Independent

Mobility aids

If applicable, please list any mobility aids

Topics your child loves to discuss

List a few topics your child loves to talk about. i.e Minecraft, dinosaurs *

About your child: *

Tip: Is there anything else that we need to know that will help make your child’s day a success?

Interests

Tick 3 things that your child enjoys or use the 'other' box if there's anything we have missed. *

Other

Medical Conditions

Please email health care plan to: info@heroesacademy.com.au

Does your child have any medical conditions? *

YES

Details:

Does your child have any allergies? *

YES

Details:

Health care plan to be emailed? *

YES

Does your child take medication? *

YES

Is the medication in a webster pack or pill planner?

YES

Please list all medication required and details for administration:

Medical profile sheet to be emailed? *

YES

Toileting

Please select all that apply *

Independent

Requires prompting

Needs assistance

Use of aids

Please provide any relevant details

Meal Times

Is assistance required during this time? *

YES

Please provide any relevant details

Menu Consent

I give permission for my child to consume the items on this menu? *

I agree

I will bring my own nut free morning tea

Emergency Contact 1

(nominated by the parent or caregiver as alternate contact)

Full name *

Contact number *

Relationship to child *

Emergency Contact 2

Full name *

Contact number *

Relationship to child *

Waiver

Although Nations Church, its staff and volunteers will exercise all reasonable care in the conduct and supervision throughout all kids programs, to the extent permitted by law, I hereby waive all liability, costs, losses or claims against Nations Church, its employees, representatives and volunteers arising out of or in connection with the child or children registered on this form. The registration form has been signed with full understanding and consideration of all of the above.

I agree that Nations Church may authorise on my child's behalf whatever medical treatment he/she may require. (This includes, but is not limited to ambulance attendance and hospital treatment). I agree to pay all medical expenses incurred.

Media release: Heroes Academy events will be captured in photographs, video and audio. Nations Church reserves the right to use the material for promotional purposes. I understand it is a condition of all registrant's entry into the program that all claims are waived in relation to inclusion of their likeness in such films or recordings. If I am a parent/guardian, I give my consent for my child to be captured on photographic, video and audio media.

I agree *

YES

Electronic signature *

Heroes Academy Mega Play Date Application Form - Bunbury

Heroes Academy Application Form - Bunbury

Parent/Guardian Details

Child

Building Your Child's Profile

Communication

Receptive

Mobility

Topics your child loves to discuss

Interests

Behaviours

Behaviours we may see when your child is not OK

Triggers

Tools/Strategies to help regulate your child

Medical Conditions

Toileting

Meal Times

Menu

Menu Consent

Emergency Contact 1

Emergency Contact 2

Waiver