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Is this registration for a person over 18 years?

First Name *

Last Name *

Address *

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Mobile Phone Number *

Age Range *

Emergency Contact

Primary emergency contact person name *

Relationship with the contact person *

Primary emergency contact person mobile number *

Child Medical

Child Date of Birth

Other details

Does your child have any medical history or allergies we need to know about?Do you have any medical conditions/disability which may affect you safely participating in any of our programs? *

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Would you like to receive updates about Melton Learning Directory programs via email and SMS? *

Does your child take any medication we need to know about in case of an emergency?

Please provide details of the medicine:

Does your child have any additional needs the program staff need to be aware of?

Other details

Has your child participated in a Melton Learning Directory program before? Have you participated in a Melton Learning Directory program before? *

Which program? *

Do you speak any language other than English at home? *

Which language?

What is your child’s gender?What is your gender? *

Do you identify as Aboriginal or Torres Strait Islander? *

Melton City Council will not be responsible for any loss, damage or injury to my person or property. Information on this form will be kept private and used only to help provide access to better services in the community. *

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