Pipeline Kids Club Starting 16 October 2025 (Term 4) • Pittwater Anglican Church

PIPELINE Kids Club Registration

Child's Details

First Name *

Last Name *

Home Address *

Suburb *

Home Postcode *

Date of Birth *

Gender

School *

School Grade *

Name of other school

Child's Email Address

Child's Mobile Number

Medical and Safety information

Does your child have Medical or Special Care Needs that we should know about? *

Are there any persons prohibited from seeing your child? *

Please state name and relationship of this person to your child. We will be in touch with you to discuss further.

Does Your Child have any Dietary Requirements or Allergies? *

Allergy information

Gluten

Dairy

Eggs

Fish/seafood

Other (including medications)

Allergies: Please provide more information

Can Paracetamol be given to your child *

Ambulance Cover *

Medicare Number *

Medicare Position on Card *

Medicare Expiry Date *

Parent / Caregiver Details

Parent Name *

Parent Mobile number *

Parent email *

Date This Form Was Completed *

Authorisations and Expectations

PLEASE READ AND RESPOND TO THE FOLLOWING STATEMENTS

After School Travel Permission

Travel from St Luke's Dee Why Campus

Pittwater Anglican Church is able provide transport from St Luke's Grammar School (Dee Why) to PIPELINE Kids Club either by bus or car driven by adults who are appropriately licenced to drive said vehicle. Your child will never be in a vehicle driven by a Learner or Provisional P1 licence holder.

Parent Consent St Luke's (Dee Why) *

I give consent for my child to be picked up from St Luke's Dee Why Campus and to travel by car or bus to Pittwater Anglican Church Mona Vale to participate in Pipeline Kids Club

I acknowledge that it will be my responsibility to inform the leaders at Pipeline Kids Club when my child will not be attending that day.

I acknowledge that if I wish to revoke consent I agree to provide Pittwater Anglican Church a written statement stating this fact.

Travel from St Luke's Bayview Campus

Pittwater Anglican Church is able provide transport from St Luke's Grammar School (Bayview) to PIPELINE Kids Club either by bus or car driven by adults who are appropriately licenced to drive said vehicle. Your child will never be in a vehicle driven by a Learner or Provisional P1 licence holder.

Parent Consent St Luke's (Bayview)

I give consent for my child to be picked up from St Luke's Bayview Campus and to travel by car or bus to Pittwater Anglican Church Mona Vale to participate in Pipeline Kids Club

I acknowledge that it will be my responsibility to inform the leaders at Pipeline Kids Club when my child will not be attending that day.

I acknowledge that if I wish to revoke consent I agree to provide Pittwater Anglican Church a written statement stating this fact.

Travel from Mona Vale Public School

Pipeline Kids Club provides a Walking Bus from Mona Vale Primary School to Pittwater Anglican Church. Two volunteer adult members of the church (who hold current Working With Children Certification as well as current Safe Ministry Certification) will meet the children at a meeting point at Mona Vale Public School and then walk them to Pittwater Anglican Church - St John's Mona Vale.

Travel from Mona Vale Public School Consent

I give consent for my child to be collected from Mona Vale Public School by members of Pittwater Anglican Church to join the Pipeline Kids Club Walking Bus from Mona Vale Public School to Pittwater Anglican Church (1624 Pittwater Rd, Mona Vale).

I acknowledge that it will be my responsibility to advise leaders of Pipeline Kids Club when my child will not be attending Pipeline Kids Club to allow the Walking Bus volunteers to know if my child is to be collected from school.

Other School

I understand that it will be my responsibility to arrange transport to Pipeline Kids Club for my child each week as there is currently no transport option offered from my child's school to Pittwater Anglican Church.

Other Permissions and Expectations

Participation Consent and Acknowledgements *

I give consent for my child to attend all scheduled Pipeline Kids Club activities, unless I advise the Pipeline Kids Club leaders otherwise.

I will provide the Pipeline Kids Club leaders with any information relevant to the wellbeing of my child prior to him or her attending Pipeline Kids Club.

I acknowledge that being part of a community involves mutual care and consideration, and therefore agree that unacceptable behaviour may result in my child being sent home and being temporarily or permanently prohibited from attending the activities of Pipeline Kids Club.

Medical Consent *

I authorise the Pipeline Kids Club leaders, in the event of an emergency, to obtain at my expense any medical, ambulance, rescue or other services that are considered necessary for my child.

Please contact me to discuss

Photo/Video Consent *

I give consent for photos/videos to be taken of my child during Pipeline Kids Club and for these images to be used appropriately in advertising or social media

I DO NOT give consent for photos/videos to be taken of my child.

If you have any questions about this permission form, email Sue Dunn: pipeline@pittwateranglican.org