CHURCHIE HOLIDAY CLINIC

Please Note: If registering more than 1 child per family, please enter their details separated by a comma in the required fields below, e.g. Name1, Name2, Name3. Age1, Age2, Age3, etc. There is no need to complete a separate form for each child.

Attendee Name *

Age *

Shirt Size * Select ... Small Medium Large

Parent/Guardian Name *

Email *

Phone *

ABC Allergy Policy

Please select child's allergy level * None Slight Mild Serious

Checkbox List * I have read the allergy policy below *

List any special medical conditions

Comments

Disclaimer I agree to the terms below **

* Allergy Policy SLIGHT reaction allergy, please list the allergies and treatment if any. MILD reaction allergy, you must call 0414 686 416 before finalising your booking to discuss the management of your child’s allergy at the clinic. SERIOUS reaction which requires an anaphylactic pen injection. Our coaches are not qualified to administer anaphylactic injections. If your child falls into this category they would need to be supervised at all times through the camp. You are also required to call 0414 686 416 before finalising your booking to discuss the allergy and your child attending our clinic.

**Terms I hereby authorise staff to act on my behalf should my child require medical attention, and release André Burger cricket from any liability for injury incurred by my child at the clinic. I understand by completing this form I will be contacted by André Burger Cricket.