Illumination Station | Kids School Holiday Program 2026 • CityReach West Church

First Child - Standard Registration 0

Child's Details

First Name *

Last Name *

Date of Birth *

Gender *

T-shirt Size *

Current Church (if applicable)

School *

School Grade *

Email Address

Primary Parent / Caregiver Details

PRIMARY: Full Name *

PRIMARY: Mobile Number *

PRIMARY: Email Address *

Relationship to Child *

Address *

Suburb *

State *

Postcode *

Secondary Parent / Caregiver Details

SECONDARY: Full Name

SECONDARY: Mobile Number

SECONDARY: Email Address

SECONDARY: Relationship to Child

Child's Medical Information

Does this child have any medical or psychological conditions that could impact them at the holiday program? *

Please provide brief details *

Has this child ever had an anaphylactic reaction? *

Please provide brief details *

Is this child currently on any medication? *

Please detail medication type and dosage *

Can Paracetamol be given as a pain killer if required? *

Child's Dietary Information

Other food allergies

Agreements

Indemnity

During the Holiday Program, some activities will be held on the grassed park adjacent to the premises. To access this area, children will, under close supervision, need to cross William Street (a no-through road).

I give consent for my child to take part in the CityReach West Kids Holiday Program to be held at Barneys Church, Croydon, on 7th-9th October.
I acknowledge that the risk of injuries is inherent in physical activities. While I am aware that workers will take all due care, I recognise that accidents may occur.
The workers have my authority to take whatever action they think necessary to ensure the safety, well-being, and successful conduct of the participants as a group or individually in the activities.
If my child becomes ill or is accidentally injured, I agree that CityReach West may obtain on my behalf whatever medical treatment my child requires. I will agree to pay all such medical expenses.
I have included information in this form concerning my child’s health, including any relevant details of his/her limitations. I also acknowledge that CityReach West and all its representative leaders or other helpers at the Kids Holiday Program can accept no liability for any personal injury or property loss suffered by my child during the period of the event.

Do you consent to your child crossing the "no through" road adjacent to the above mentioned premises, under the close supervision of CityReach West leaders and helpers for the purpose of large group activities? *

In attending CityReach West Kids Holiday Program, you consent to your child’s participation in a range of general activities, craft making, singing and dancing.

Please specify if there are any specific activities that you do not wish your child to participate in?

Behaviour Guidelines

At CityReach West Kids Holiday Program, we want to ensure the safety and well-being of everyone. We are committed to fostering an environment where each individual can thrive, learn and grow while upholding the values of personal responsibility, respect and Christian love. It is important that all children, leaders, support staff and volunteers are safe and feel safe during this program. We want everyone to have a sense of care for self, others, and the community.

Care for Self:

Personal Responsibility: Take ownership of your belongings, keep the area tidy and participate in activities.
Medication: All medications, including painkillers, must be given to and distributed by the dedicated First Aid Officer.
Electronic Devices: We kindly ask that no electronic devices be brought to the Kids Holiday Program by children.
Appropriate Dress: Wear clothing suitable to the activity; consider sun-smart options – hat, sunglasses and long sleeves when outside.
Leaving the Site: Once checked in, children will not leave the premises until checked out (with the exception of the designated outdoor activity across the road for which CityReach West has received prior permission from the parents/guardians as noted above).

Care for Others:

Sickness/Accidents: Children who are not feeling well or are injured will have access to the First Aid Officer and can inform a leader who will get help.
Respect for Others: Treat fellow children with kindness, respect and Christian love, reflecting Christ’s teachings in all interactions.
Positive Language: Use uplifting and positive language, refraining from profanity and negative speech.
No Bullying or Harassment: Refrain from any form of bullying, harassment or exclusion, promoting an environment of Christian love and support.

Care for Community:

Safety First: Follow safety guidelines and Kids Holiday Program leaders’ instructions to ensure a secure and enjoyable experience for all.
Fire: In case of a fire, follow the instructions to assemble safely in the designated area and avoid returning to retrieve belongings.

I acknowledge that CityReach Kids adopts and uses the Behaviour Management Plan, as below:

Our policy for any negative disruptions or behavioural matters will be dealt with in the following way:

STEP 1: First warning

STEP 2: Time Out (relocated away from the group, under the supervision of a helper)

STEP 3: In the case of negative behaviour continuing, parents will be contacted via SMS/phone call requesting them to come and assist with the management of the child’s behaviour.

I agree that I/my child will abide by the rules of the Kids Holiday Program and direction of the leaders. *

Protecting Your Privacy

Protecting your privacy is important to CityReach West. The information we seek allows us to manage risk, provide reasonable care and administer your child’s involvement in our program. We are careful to keep your information confidential and provide it only to those agents acting on behalf of the organisation who need it to enable them to perform their agreed activities (eg. The first-aider in charge). You are welcome to contact us in relation to issues regarding your personal information and for a copy of our Privacy Policy. We only ask for information that is necessary for the purposes outlined in this statement. In some circumstances, if you don’t provide us with all the requested information, your child could miss the opportunity to be involved in our program.

Would you like to be contacted about CityReach West Kids Holiday Programs in the future? *

Do you consent to a leader continuing contact with your child after the Holiday Program, within CityReach West policy guidelines? *

CityReach West records the variety of activities that our participants engage in. We hope that the photos that are taken can be used by us to further document/promote our activities. This may include, but is not limited to, placement on our webpage or placement on social media. In order to do this, we need parental permission to take children’s photos and use their images. If you do NOT want your child’s image to be used in any of our promotional material, you need to indicate below. If you agree for your child to have their image recorded, both as photographs and video footage, you acknowledge and agree that:

The use of such images will be in accordance with the Copyright Act 1968;
Images may be displayed in public contexts (in South Australia, interstate, and/or overseas);
CityReach West may edit or choose not to use certain images;
No payment or further compensation will be made for the use of these images; and
You release CityReach West from any claims arising from this use.

Do you consent to the appropriate use by us of photographs of the CityReach West Kids Holiday Program that include you/your child? *

Anything Else?

Is there anything else you would like to ask us / tell us? *

Please specify *

I, the legal guardian of the child mentioned above, give permission for my child to be involved in the CityReach West Holiday Program.

Parent's / Guardian's Full Name as signature *

Date Completed *

We are committed to caring for you and protecting your privacy, so we collect information solely for the purpose of ministry and related activities of CityReach West. By submitting this form, you consent for CityReach West to retain and process your information and contact you accordingly. To learn more, please see our Privacy Policy.

Consecutive Child - Standard Registration 0

Child's Details

First Name *

Last Name *

Date of Birth *

Gender *

T-shirt Size *

Current Church (if applicable)

School *

School Grade *

Email Address

Primary Parent / Caregiver Details

PRIMARY: Full Name *

PRIMARY: Mobile Number *

PRIMARY: Email Address *

Relationship to Child *

Address *

Suburb *

State *

Postcode *

Secondary Parent / Caregiver Details

SECONDARY: Full Name

SECONDARY: Mobile Number

SECONDARY: Email Address

SECONDARY: Relationship to Child

Child's Medical Information

Does this child have any medical or psychological conditions that could impact them at the holiday program? *

Please provide brief details *

Has this child ever had an anaphylactic reaction? *

Please provide brief details *

Is this child currently on any medication? *

Please detail medication type and dosage *

Can Paracetamol be given as a pain killer if required? *

Child's Dietary Information

Other food allergies

Agreements

Indemnity

I give consent for my child to take part in the CityReach West Kids Holiday Program to be held at Barneys Church, Croydon, on 7th-9th October.
I acknowledge that the risk of injuries is inherent in physical activities. While I am aware that workers will take all due care, I recognise that accidents may occur.
The workers have my authority to take whatever action they think necessary to ensure the safety, well-being, and successful conduct of the participants as a group or individually in the activities.
If my child becomes ill or is accidentally injured, I agree that CityReach West may obtain on my behalf whatever medical treatment my child requires. I will agree to pay all such medical expenses.
I have included information in this form concerning my child’s health, including any relevant details of his/her limitations. I also acknowledge that CityReach West and all its representative leaders or other helpers at the Kids Holiday Program can accept no liability for any personal injury or property loss suffered by my child during the period of the event.

In attending CityReach West Kids Holiday Program, you consent to your child’s participation in a range of general activities, craft making, singing and dancing.

Please specify if there are any specific activities that you do not wish your child to participate in?

Behaviour Guidelines

Care for Self:

Personal Responsibility: Take ownership of your belongings, keep the area tidy and participate in activities.
Medication: All medications, including painkillers, must be given to and distributed by the dedicated First Aid Officer.
Electronic Devices: We kindly ask that no electronic devices be brought to the Kids Holiday Program by children.
Appropriate Dress: Wear clothing suitable to the activity; consider sun-smart options – hat, sunglasses and long sleeves when outside.
Leaving the Site: Once checked in, children will not leave the premises until checked out (with the exception of the designated outdoor activity across the road for which CityReach West has received prior permission from the parents/guardians as noted above).

Care for Others:

Sickness/Accidents: Children who are not feeling well or are injured will have access to the First Aid Officer and can inform a leader who will get help.
Respect for Others: Treat fellow children with kindness, respect and Christian love, reflecting Christ’s teachings in all interactions.
Positive Language: Use uplifting and positive language, refraining from profanity and negative speech.
No Bullying or Harassment: Refrain from any form of bullying, harassment or exclusion, promoting an environment of Christian love and support.

Care for Community:

Safety First: Follow safety guidelines and Kids Holiday Program leaders’ instructions to ensure a secure and enjoyable experience for all.
Fire: In case of a fire, follow the instructions to assemble safely in the designated area and avoid returning to retrieve belongings.

I acknowledge that CityReach Kids adopts and uses the Behaviour Management Plan, as below:

Our policy for any negative disruptions or behavioural matters will be dealt with in the following way:

STEP 1: First warning

STEP 2: Time Out (relocated away from the group, under the supervision of a helper)

STEP 3: In the case of negative behaviour continuing, parents will be contacted via SMS/phone call requesting them to come and assist with the management of the child’s behaviour.

I agree that I/my child will abide by the rules of the Kids Holiday Program and direction of the leaders. *

Protecting Your Privacy

Would you like to be contacted about CityReach West Kids Holiday Programs in the future? *

Do you consent to a leader continuing contact with your child after the Holiday Program, within CityReach West policy guidelines? *

The use of such images will be in accordance with the Copyright Act 1968;
Images may be displayed in public contexts (in South Australia, interstate, and/or overseas);
CityReach West may edit or choose not to use certain images;
No payment or further compensation will be made for the use of these images; and
You release CityReach West from any claims arising from this use.

Do you consent to the appropriate use by us of photographs of the CityReach West Kids Holiday Program that include you/your child? *

Anything Else?

Is there anything else you would like to ask us / tell us? *

Please specify *

I, the legal guardian of the child mentioned above, give permission for my child to be involved in the CityReach West Holiday Program.

Parent's / Guardian's Full Name as signature *

Date Completed *

While many people claim to know about Jesus, the Light of the world, many are in the dark about who He really is.

Location

Date & Time

First Child - Standard Registration 0

Child's Details

Primary Parent / Caregiver Details

Secondary Parent / Caregiver Details

Child's Medical Information

Child's Dietary Information

Agreements

Indemnity

Behaviour Guidelines

Protecting Your Privacy

Anything Else?

I, the legal guardian of the child mentioned above, give permission for my child to be involved in the CityReach West Holiday Program.

Consecutive Child - Standard Registration 0

Child's Details

Primary Parent / Caregiver Details

Secondary Parent / Caregiver Details

Child's Medical Information

Child's Dietary Information

Agreements

Indemnity

Behaviour Guidelines

Protecting Your Privacy

Anything Else?

I, the legal guardian of the child mentioned above, give permission for my child to be involved in the CityReach West Holiday Program.