Berry Street Web Docs KTA Shepparton

Other Special Needs/Disability/Behavioural Issues: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Emergency Contact: Name: ______________________________________________________________________ Phone: ______________________________________________________________________ Relationship to Child: _________________________________________________________ Activity Participation (parent to complete): I _____________________________________________understand that all due care will be taken by Kid’s Turn Around Facilitators to seek appropriate medical assistance in an emergency and to contact my child’s parents as soon as practicable. I further authorise the use of an ambulance if in the facilitator’s judgement it is necessary. I accept responsibility for payment of all expenses associated with such treatment. Attendance Commitment (parent to complete): I will ensure that my child ___________________________________ will attend all sessions as required by the program. Signed Date Rachel Williams Kid’s Turn Around Berry Street PO Box 1108 Shepparton 3632 Ph. 0358 228 100 © Berry Street, Post Separation Services, Kid’s Turn Around Application Form, Updated Aug 2011 Page 2

Berry Street Web Docs KTA Shepparton | Page 2