Registration Form

After purchasing your tickets, please fill out this form.

Parent / Guardian One:

Name

Relationship to Active Gamer

Best contact number

Alternative contact number

Address

Contact Parent / Guardian in case of emergency.

Parent / Guardian Two:

Name

Relationship to Active Gamer

Best contact number

Alternative contact number

Address

Contact Parent / Guardian in case of emergency.

Details of additional people who can collect your Active Gamer.

Name of alternative person to collect Active Gamer.

Alternative person's contact number

Active Gamer's Information

Name

Age

Gender Male Female

Name

Age

Gender Male Female

Name

Age

Gender Male Female

Name

Age

Gender Male Female

Name

Age

Gender Male Female

Any notes about the above Active Gamers. Eg siblings do/don't want to do activities together.

Active Gamers Health Information

Does your Active Gamer participate in sport or physical activity at school or within a club?

Any dietary restrictions?

Heart Condition?

Diabetes?

Childhood epilepsy?

Any bone, joint or muscular problems including arthritis?

Asthma or other respiratory probblems?

Any alergies?

Diagnosed with ADHD or Autism Spectrum Disorder?

Any other personality or behavioural considerations?

Any sight or hearing impairments?

Any other medical conditions for us to be aware of?

Any medication? Please contact us to discuss any management plans you have in place or special needs that staff should be aware of.

Lunch Options

Monday lunch

Tuesday lunch

Wednesday lunch

Thursday lunch

Friday lunch

If you are sending more than one Active Gamer please put their lunch order here.

Authorisations

I understand that participating in physical activity for my Active Gamer carries a risk and I accept all responsobility for that risk.* Yes No

I have ambulance cover Yes No

I authorise Active Gamer staff to obtain, at my cost, medical or ambulance assistance in the case of an accident or emergency. Yes No

I agree that Active Gamers Australia accepts no liability, financial or otherwise, for any injuries or accidents that occur during the program. Yes No

I understand that if my Active Gamer fails to behave in a manner that is polite and social, they could be suspended from that particular activity or sent home. Yes No

I will not bring my child to the Active Gamer program if they are at risk of passing on an infectious disease or are experiencing vomiting and diarrhoea. Yes No

I consent to Active Gamer Australia photographing or videoing my Active Gamer during their time in the program for promotional purposes. Yes No

I acknowledge that I have read this form in its entirety and have answered the questions accurately and to the best of my knowledge. Yes No

I will inform Active Gamer staff immediately if there are any changes to the information provided. Yes No

Weather permitting, we will be going to the Phillip Swimming Centre. Would you like you Active Gamer to visit the pool*

How do you first hear about us?

Other

Parent / Guardian signature.*

Name*

Please email this to me

Your registration is complete.

We will be in touch shortly.