FAMILY REGISTRATION FORM.

PERSON/S WHO LIVE WITH PARENT/GUARDIAN 1 PARENT/GUARDIAN 2

THE PARTICIPANT

FIRST NAME: Darcee Joshua

SURNAME: Campion Huggins

RELATIONSHIP TO THE Mother Father

PARTICIPANT:

DATE OF BIRTH: 08/10/1998 24/04/1997

RESIDENTIAL ADDRESS: 559 Moffat Street 559 Moffat Street

TOWN: Lavington Lavington

HOME PHONE: Click or tap here to enter text. Click or tap here to enter text.

MOBILE PHONE: 0484780561 0498454508

EMAIL ADDRESS: darcee19@icloud.com josh_holden_12@hotmail.com

PLACE OF WORK: Lavington Lavington

WORK/STUDY PHONE: Click or tap here to enter text. Click or tap here to enter text.

EMPLOYMENT STATUS: casual Full time

OCCUPATION: Disability care Tiling

COUNTRY OF BIRTH: Australia Australia

ETHNIC ORIGIN: n/a n/a

PRIMARY LANGUAGE: English English

CLIENT OF: Click or tap here to enter text. Click or tap here to enter text.

SIBLINGS: 2, Eli & Isabelle 2, Eli & Isabelle

PARTICIPANT DETAILS: PARTICIPANT 1 PARTICIPANT 2

PARTICIPANT FULL NAME: Grace Marree Huggins Click or tap here to enter text.

RESIDENTIAL ADDRESS: 559 Moffat Street Lavington Click or tap here to enter text.

BIOLOGICAL MOTHER FULL Darcee Campion Click or tap here to enter text.
NAME:
BIOLOGICAL FATHER FULL Click or tap here to enter text. Joshua Huggins
NAME:

1
 FAMILY REGISTRATION FORM.

GENDER: Female Male

DATE OF BIRTH: 30/04/2020 Click or tap here to enter text.

SCHOOL ATTENDING: Click or tap here to enter text. Click or tap here to enter text.

YEAR STARTED SCHOOL: Click or tap here to enter text. Click or tap here to enter text.

COUNTY OF BIRTH: Australia Click or tap here to enter text.

ETHNIC ORIGIN: Click or tap here to enter text. Click or tap here to enter text.

PRIMARY LANGUAGE: English Click or tap here to enter text.

RELIGIOUS/CULTURAL n/a Click or tap here to enter text.

REQUIREMENTS:
IS THERE A COURT ORDER n/a Click or tap here to enter text.
AFFECTING CUSTODY:
IS THE PARTICIPANT FULLY Yes Click or tap here to enter text.
IMMUNISED: (please provide
copy of immunisation).
IS THERE DIAGNOSED n/a Click or tap here to enter text.
MEDICAL CONDITIONS: e.g.
Asthma/diabetes/risk of
anaphylaxis?
DO YOU SUSPECT THERE IS AN n/a Click or tap here to enter text.
UNDIAGNOSED MEDICAL
CONDITION: e.g.
Asthma/diabetes/risk of
anaphylaxis?
DISABILITY: n/a Click or tap here to enter text.

ALLERGIES/CULTURAL OR n/a Click or tap here to enter text.

SPECIAL DIETARY
REQUIREMENTS:
REGULAR MEDICATION: n/a Click or tap here to enter text.

AUTHORISED TO COLLECT: 1. CONTACT 2. CONTACT

must be over 18.
RELATIONSHIP TO Mother Father
PARTICIPANT:

NAME: Darcee Campion Joshua Huggins

ADDRESS: 559 Moffat Street 559 Moffat Street

TOWN: Lavington Lavington

PHONE: Click or tap here to enter text. Click or tap here to enter text.

MOBILE: 0484780561 0498454508

2
 FAMILY REGISTRATION FORM.

WORK PHONE: Click or tap here to enter text. Click or tap here to enter text.

WORK PLACE: Abundant life Campion tiling

MEDICAL INFORMATION

FAMILY DOCTOR: The Doctors @ Lavington

PHONE: 60577100

ADDRESS: 347 Wagga Road Lavington

MEDICARE NUMBER INCLUDING POSISION 2785 44541 5 Position : 3

PLACED ON CARD: IE: NUMBER 3

AMBULANCE COVER HELD: Click or tap here to enter text.

HEALTH FUND: Click or tap here to enter text.

SPECIALIST DOCTOR: Click or tap here to enter text.

PHONE: Click or tap here to enter text.

ADDRESS: Click or tap here to enter text.

TREATING FOR: Click or tap here to enter text.

PARENT DECLARATION AND AGREEMENT:

I have read all information and terms in my contract with Katrina Thompson trading as Kat’s Care
Services. By completing and returning this registration form you are agreeing to the terms and
conditions of Kat’s Care Services. Please make any comments below e.g.: no participant photos.

Click or tap here to enter text.

PRINT NAME SIGNATURE DATE

Darcee Campion Darcee campion 12/06/2022