Pulse First Timers Card

St Alfred's Anglican Church

You can use this form to tell us about yourself so we can keep you in the loop with what is happening at Pulse.

About you

This information is for the person attending Pulse.

First Name *

Last Name *

Email Address

Mobile *

Gender *

Date of Birth *

Year Level *

School

Who invited you to Pulse? *

Do you have parent/guardian permission to attend? *

Parent / Guardian

We will keep this person updated about things that are happening at Pulse (as well as yourself). It is also good to know who we should call just in case.

Parent's First and Last Name *

Parent's Mobile *

Parent's Email *

Health information

This information will help leaders look after you should the need arise. It is your responsibility to make sure this information is accurate and kept up to date. For serious conditions you should also speak to the senior leader of the group(s) and make sure the leader understands your expectations.

About your health

Medical Conditions *

NO MEDICAL CONDITIONS KNOWN

ADHD

Anaphylaxis

ASD

Asthma

Migraines

Epilepsy

Fits of any type

Diabetes

Heart condition

Bleeding (nose / other)

Blackouts / dizzy spells

Other (Add note in Medical Conditions Other below)

Medical Conditions Other

Known allergies other than food

Details of any recent illness or surgery that Leaders need to be aware of

Medication

Details of Medication

Who is to administer medication

Self

Leader

Other responsible adult

Food requirements

This information will be passed on to kitchen staff so they can prepare meals/snacks if part of the program. If there are external events such as camps then this information will be passed on to third parties as appropriate.

Food Requirements *

NO FOOD ISSUES KNOWN

Anaphylaxis (please provide additional information under the Food Comments field)

Coeliac / Gluten int.

Egg allergy

Fructose int.

Lactose int.

Nut allergy

Seafood Allergy

Vegan

Vegetarian

Other (please provide additional information under the Food Comments field)

Food Requirements Other