Child Minding Form

All participants of the Check Me Out Roadshows that will need the child minding service must complete the form below. Please note: If you are attending the MONBULK or YARRA JUNCTION Roadshow events, please follow the link below to the child minding form linked to those events.

Monbulk Roadshow Form

Yarra Junction Coming Soon

Child's Full Name

Child's Date of Birth

Parent/Guardian Full Name:

Parent/Guardian Address:

Parent/Guardian Telephone Number:

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Parent/Guardian Relationship to Child:

Emergency Contact 1 Name: (other than Parent/Guardian listed above)

Emergency Contact 1 Address:

Emergency Contact 1 Telephone Number:

(###)

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Emergency Contact 1 Relationship to Child:

Emergency Contact 1 Authorized to Collect Child:

Emergency Contact 1 Authorized to Consent Medical Treatment/ Medications:

Emergency Contact 2 Name: (other than Parent/Guardian listed above)

Emergency Contact 2 Address:

Emergency Contact 2 Telephone Number:

(###)

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Emergency Contact 2 Relationship to Child:

Emergency Contact 2 Authorized to Collect Child:

Emergency Contact 2 Authorized to Consent Medical Treatment/ Medications:

Name Family Doctor/Medical Service:

Family Doctor/Medical Service Telephone Number:

Family Doctor/Medical Service Address:

Childs Medicare Number:

Child Medical Information:

Has your child been diagnosed at risk of Anaphylaxis?

Does your child have an Auto Injection Device (EpiPen)?

Does your child have a Anaphylaxis Medical Managment Plan?

Has your child been diagnosed with Asthma?

Does your child have a Asthma Medical Management Plan?

None of the above

If you answered yes to any of the above, please email medical plans to contact@mumsofthehills.com.au and confirm below once completed:

Child Immunisations:

Based on your response above, please email Immunization statement or exemptions to contact@mumsofthehills.com.au and confirm below once completed:

I understand that medical plans and immunizations statement/exemptions need to be emailed through. Without them, my child will not be able to attend the session:

Yes I understand

I declare that all the information is complete and accurate. I understand and agree that at all times my child/ren shall be at my own risk and I will not hold the incorporated group (Mums of the Hills Inc.), the venue or its staff liable for any personal injury which may result to my child/ren or loss of property, except for the liability by the incorporated group if it fails to render its services with due care and skill or supplies any material in connection with those services which is not reasonably fit for the purpose for which they are supplied.

I agree

I disagree