This form is required to be completed by the parent/guardian of any person under 18 who would like to participate in the Harrow Neighbourhood House School Holiday Program
which is a program managed by the Harrow Bush Nursing Centre. All information on this form is treated strictly confidential and is valid for the calendar year of submission, covering all activities of the school holiday program of that particular year. If there are any changes that occur to the information provided after this form is submitted, please advise the Harrow Bush Nursing Centre as soon as possible. If you indicate on this form that your child has a health condition that requires an Action Plan for example Anaphylaxis or Asthma, this is required to be emailed separately to firstname.lastname@example.org
. If you have any concerns or questions, please contact us on (03) 5588 2000.
EMERGENCY CONTACT INFORMATION
Please provide details of people we can contact in the event of an emergency. Do not include the person above.
Do you have ambulance cover?
Do you have a Healthcare Card?
Is your family a member of the Harrow Bush Nursing Centre?
If not and you are interested in becoming a member, please see Reception at the centre to discuss the benefits of membership to the Harrow Bush Nursing Centre.
Has your child been diagnosed with any of the following conditions (check the boxes)?
NOTE: If you have selected any of the options above, and you have a Medical Action Plan which we need to be aware of, please email a copy of this plan to email@example.com
or bring the plan/s into the Harrow Bush Nursing Centre in person.
Does your child have any other allergies we should be aware of?
Does your child have any diet requirements?
Are there any other medical conditions that staff need to be made aware of that may impact on the undertaking of an activity?
At the request of Harrow Bush Nursing Centre, I hereby consent to the reproduction of photographs in which my child appears, in any Harrow Bush Nursing Centre publications, displays or paid advertising relating to the promotion of the Harrow Bush Nursing Centre and the School Holiday program: also in any publications (including the internet, newspapers and magazines) produced by any other agencies to which the Harrow Bush Nursing Centre might supply the photographs for the general purpose of the promotion of the Harrow Bush Nursing Centre and School Holiday Program.
Please check these boxes below to confirm you agree. If you do not or are unable to check ALL the boxes, your child may not be able to participate in the school holiday program. We will contact you to discuss the options.