Inflame Youth Permission Note 2025 • Christian Life Church Kyogle

First Name *

Tip: Youth first name

Last Name *

Date of Birth *

Tip: Youth's Birthday NB Month/Day/Year American style

Email Address

Mobile Number

Home Address *

Home City *

Home Post Code *

School Grade *

Parents/Guardians names *

Parents/Guardians phone number *

Parents/Guardians email address *

Does your youth have any special dietary requirements or allergies?

Medical Conditions

Other Medical Conditions

Does your youth suffer from the following drug allergies:

Does your youth self medicate or do they need assistance? (Please add details)

Does your youth have any special needs that you would like us to be aware of

Medicare Number *

When was your youth's last tetanus injection? NB At 4 years and 12 years of age a Tetanus injection is included in the scheduled immunisation *

During the Inflame program there may be times when the youth leaders run activities within walking distance of the church. *

I give permission for my youth to participate in these activities

I do not give permission for my youth to participate in these activities

Please be aware that CLC and Inflame Youth leaders hold no responsibility for your child before they sign in (from 4pm) and after they sign out. Last sign out is 5.45 pm. *

I do give permission for my child to leave without a delegated responsible person

I do not give permission for my child to leave without a delegated responsible person

Let us know who the responsible persons are that can pick up your youth. Please include phone numbers. *

Do you give permission for CLC to publish photos of your young person on our social media pages/website/YouTube? *

I acknowledge that CLC Kyogle Inflame Youth will be responsible for my child/ren for the duration of the program ONLY. (4pm - 5:45pm) *

Yes

No