MY New Kids Form • The Pulse

Parent Information

First Name *

Last Name *

Gender *

Email Address *

Phone Number *

Date of Birth

Street Address *

Suburb *

Postcode *

Relationship to Child/Children? *

Does the child/children live with you? *

YES

NO

Secondary Contact

Full Name *

Contact Number *

Relationship to the child/children? *

Does the child/children live with you? *

YES

NO

Further Information

Please Tick *

This is just a one off visit

We are interested in coming again

Campus *

Myaree

Belmont

Port Kennedy

Service time *

9AM

10AM

11AM

6PM

Children's Details

Full Name *

Date of Birth *

Gender *

Male

Female

Media Release

I consent for Nations Church to use the images and words through video and/or photograph of the child or children registered on this form for the purpose of editorial, promotion, communications or public relations.

I agree *

YES

NO

Disclaimer

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 *

YES

NO

Electronic Signature *