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2008 Reflector Permission Form
Please take a moment to fill in this permission form as it will further help
us ensure the safety of all young people participating in reflector
activities. This form will cover all weekly reflector activities for 2007,
excluding only extraordinary events such as camps & road trips.
Youth Details
Name: ______________________________________________
D.O.B: _______________________
Address: ______________________________________________
Home Phone: ______________________________________________
Mobile: ______________________________________________
Email: ______________________________________________
Parent Details
Name/s: ______________________________________________
Address: ______________________________________________
Home Phone: ______________________________________________
Mobile: ______________________________________________
Email: ______________________________________________
Emergency Contact Details
Emergency contact name: ______________________________________________
Phone No: _______________________
Relationship to young person: __________________________________________
Ambulance Cover: YES / NO Ambulance Cover No: _______________________
Health Care Card YES / NO Medicare No: _______________________
Food allergies:
_____________________________________________________________________________
_________________________________________________________________________________________
Other relevant medical information:
_____________________________________________________________
_________________________________________________________________________________________
I give permission for my child to take part in reflector activities &
programs, understanding that all reasonable measures will be taken to insure
their safety while participating in activities.
Name: ______________________________________________
Signed: ______________________________________________
Date: _______________________
I give permission for my child to be photographed / videod while
participating in reflector activities.*
Signed: ______________________________________________
Date: _______________________
* These photographs/video will only be used for promotional purposes and
will only be distributed to those people actively involved in reflector.
Pics/video are put on the reflector website or notice board for reflector
youth, their parents and the wider church to access and enjoy.
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