Term 1 2021 Registration Form

Participant Full Name

First

Last

Participant Date of Birth

day

month

year

Parent/Guardian Name

First

Last

Parent/Guardian Phone

Parent/Guardian Email

Preferred Contact Method

Phone

In the event of an accident, injury or illness, I authorise a member of The Misfit Project Staff to seek medical intervention for the participant.*

Yes

I give permission for the partipant to be administered Paracetamol (Panadol) as per manufacturers instructions by a supervising adult if deemed necessary.

Yes

Please provide us with any medical or mental health information we need to know support you to access our programs

Please list any allergies below

The MISFIT Project hopes to use imagery to highlight project achievements, for training purposes and for social media use (including advertising). Please indicate whether you give permission for the above uses.

I give permission for use across all platforms

I do not give permission

I would like to arrange specific conditions for the use of imagery (please specify)

Does the participant have an NDIS plan?

Yes

Emergency Contact Name (different from the Parent/Guardian listed above)

First

Last

Emergency Contact Phone

Relationship to Participant?