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Cowra Summer Breakout 2026 - Rego Form

Child's Name: *

School Year in 2026 *

Name of Parent/Caregiver *

Address: *

Phone Number: *

Emergency Contact (Full Name): *

Emergency Contact (Phone Number): *

Medical conditions, food allergies or anything else we should be aware of (if none, please state 'None') *

The information collected in this form will NOT be used for any commercial purposes but may be used for future contact regarding breakout and other ministries *

Yes, I consent to future contact.

No, I do not consent to future contact.

Photos may be taken and used for Cowra Summer Breakout purposes only. *

Yes, I consent to photos.

No, I do not give consent for photos to be taken.

Child Pickup: Please specify if your child may be picked up by someone other then yourself, if so, please list their full name(s) below:

(For years 3-12 only): Weather permitting, they may be taken by leaders directly across the road from the Baptist church (Rodwell Oval), a 30 second walk, for some of the Breakout program / activities. *

Yes, I consent

No, I do not give consent

Not applicable

For Teenagers Only (School years 7-12): I give permission for my child to attend the Breakout activities held at the Baptist, Presbyterian or Anglican Churches and at other local venues during the course of the week. *

Yes, I give my consent.

No, I do not give my consent.

Not applicable

(Question for Parent/Care Giver): I would be interested in coming to adult night events during the week of Breakout *

Yes

(Question for Parent/Care Giver): I am interested in being contacted to speak to someone about life and faith *

Yes

Signature *common.clear

Date *

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