Playgroup - Registration - Childhood Cancer Association

Children details

Children

Add all children that will be attending the playgroup

Contact details

Parent/Guardian details

Primary caregiver name

First name

Last name

Relationship to child

Email address

Phone number

Address

Emergency contact details

Emergency contacts

Enter in order of priority. Minimum 2 emergency contacts.

Consent

Photo/Video Consent for Childhood Cancer Association & Hospital School SA

I consent for photographs and/or video’s of my child/ren to be used for learning documentation purposes.

I give my consent:

Yes

No

I consent for photographs and/or videos of my child/ren to be used for external advertising of the playgroup service. This may include social media, newsletters, flyers, brochures and posters.

I give my consent:

Yes

No

Research & Grant Application Consent

I consent for my child/ren’s photos/videos and de-identified information to be used as part of any research that evolves from my child’s participation in the Playgroup or in grant applications to support ongoing funding of the program. I understand that while information gained during this program may be published, neither my child nor any other family member will be identified. I understand that all information will remain anonymous. Any photos/videos used will not be linked to an individual child progress.

I give my consent

Yes

No

Confidentiality and Information Storage

All personal information gathered during the provision of the Playgroup will remain confidential and secure. All physical records will remain in secure storage at the Childhood Cancer Association and Hospital School SA, who will have access to your details to ensure that they are able to appropriately support your child/ren. All facilitators may share relevant information with each other to ensure the effective running of the program.

Consent

I hereby consent to the registration of my child/ren in the Childhood Cancer Association's Playgroup, run in partnership with the Hospital School SA. I understand and agree to the information outlined in this consent form.

Name

First name

Last name

Signature

Date

Playgroup Registration Enquiry

(for children aged 1-5 years)

Parent/Guardian details

Emergency contact details

Photo/Video Consent for Childhood Cancer Association & Hospital School SA

Research & Grant Application Consent

Confidentiality and Information Storage

Consent