Step 1 of 3

Club Location

Please select a Club*(Required)

Child/ren's Information

Child/ren's Information(Required)

Child's Full Name

DOB (dd/mm/yyyy)

PCYC Membership Number

Parent/Guardian & Emergency Contact Information

Parent/Guardian Full Name(Required)

DOB (dd/mm/yyy)(Required)

Relationship to Child/ren(Required)

Email*(Required)

Phone*(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Second Emergency Contact

Full Name*(Required)

Relationship to Child/ren*(Required)

Phone*(Required)

Health, Medical Conditions & Complex Behaviour(Required)

If your child/ren has been diagnosed with any Health or Medical Conditions, is known to display symptoms of Complex Behaviour or demands any Special or Dietary Needs, please fill out the PCYC Health & Medical Form, available on your PCYC Club page.

Applicable

Not Applicable

File

Max. file size: 40 MB.

Media Permission(Required)

I give permission for my child’s photographic and/or video image, voice and/or words to be used for promotional purposes in official publications of the Police & Citizens Youth Clubs NSW

I do not give permission

Indemnity Statement(Required)

I the parent/guardian, have read and agree to Terms & Conditions outlined and:

I agree for my child/ward to attend the Centre and to undertake all activities and/or to participate in the above program. In the case of an emergency, I authorise PCYC, where it is impracticable to communicate with me, to arrange for my child/ward to receive such medical or surgical treatment as may be deemed necessary. I also undertake to pay or reimburse costs which may be incurred for medical attention, ambulance transport and drugs while my child/ward is attending the Centre/enrolled in the program. I understand that although PCYC and its service providers attempt to minimise any risk of personal injury within practical boundaries, accidents do happen, and all physical activities carry the risk of personal injury. I acknowledge that there is an inherent risk of personal injury in physical activities that will be undertaken at the Centre/as part of the program, and I accept that risk.

I, the undersigned, accept full responsibility for my child/ren’s personal belongings and for my child/ren’s behaviour during the program and in the event of misbehaviour I will be contacted and asked to collect my child/ren.

School Holiday Program Enrolment Request

Club Location

Child/ren's Information

Parent/Guardian & Emergency Contact Information

Second Emergency Contact

Booking Request

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School Holiday Program Enrolment Request

Club Location

Child/ren's Information

Parent/Guardian & Emergency Contact Information

Second Emergency Contact

Booking Request

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