Q-TRACK

Contact Information

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First Name

Last Name

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Participant Details

Participant Details These sessions are Stay & Play sessions. We encourage Parents and Carers to stay and feel part of the sessions

First Name

Last Name

DOB

Please let us know if your child has any Special Education Needs or Disabilities?

What techniques can we use to put your child at ease if they are feeling anxious?

Child / personal photo consent: I hereby give permission for photographs to be taken which may be published on social media, in local news papers, brochures, displays.

Yes

Medical Information

Detail any medical conditions

Details of all medical conditions or allergies (e.g Asthma, Diabetes, Epilepsy) and any other medications

If the above-named child experience illness or an accident, as the responsible parent/carer, I authorize the administration of first aid by a trained first aider, if available, or by a qualified medical professional when deemed necessary.

Yes