Parent/Guardian Name *

First Name

Last Name

In the event of an emergency, I authorise the playgroup volunteers/coordinators to seek medical assistance for my child/children if I am unable to be contacted. *

Yes

No

Emergency Contact Name

First Name

Last Name

Child 1 Name *

First Name

Last Name

Child 1 Date of Birth *

MM

DD

YYYY

Child 1 Gender *

Male

Female

Child 2 Name (if any)

First Name

Last Name

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Gender

Male

Female

Child 3 Name (if any)

First Name

Last Name

Child 3 Date of Birth

MM

DD

YYYY

Child 3 Gender

Male

Female

Does your child have any allergies?

Yes

No

I understand that I am responsible for supervising my child/children at all times during playgroup.

I permit my child/children's photo to be used in the playgroup's purposes (e.g., promotions, displays, or social media).

I agree to follow the playgroup’s safety and behaviour guidelines.

I agree to notify the playgroup leaders of any changes to the information provided above.