Child Participant Details

Classes you plan to attend (tick all that apply):

    Learning ClubKarate - IntermediateOther

    If Other, please specify

    Participant Details

    Name (required)

    Date of Birth (required)

    Gender (required)



    Cultural Background

    Medical Conditions or Allergies

    Parent/Carer Details

    Parent/Guardian Name (required)

    Address (required)

    Suburb (required)

    Postcode (required)

    Email (required)

    Contact Number (required)

    Healthcare Card Holder

    Are you an Aboriginal or Torres Strait Islander?

    Alternate Contact Name (required)

    Alternate Contact Number (required)

    Do you give permission for another adult to take your child home after the program?

    If “Yes” to above question, please provide name & contact number:

    Do you give permission for your child to go home alone?

    In the event of a medical emergency, do you give permission for Railway House staff to administer basic First Aid to your child and to seek emergency medical assistance?

    Do you give permission for photographs of the child/ren listed on this form to be used in Railway House promotional materials?


    I consent to my child’s participation in the activity and acknowledge that I fully understand my child’s participation may involve risk of serious injury, illness, or death, including losses which may result not only from my child’s own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the activity is being conducted, and/or the rules of play of this type of activity. I understand that if I have any risk concerns, I shall discuss them completely with the staff before I sign this agreement and before my child’s participation in the activity begins. Knowing and understanding the risks involved with participation in the activity, I hereby voluntarily and willingly assume full and complete responsibility for all losses and damages, including injury, illness, and death, resulting from my child’s participation in the activity. I agree I am financially responsible for any losses and damages resulting from my child’s participation in the activity.


    All personal information is kept confidential and in accordance with information privacy laws. Please contact us if you would like further details on our privacy policy.


    Please contact the office to make your payment. The following methods of payment are accepted:

    Card (preferred) either in the office or over the phone
    Cash in the office
    Bank Transfer

    Bank details:
    Account Name: North Carlton Railway Neighbourhood House
    BSB: 313 140
    Account: 1205 4263

    We acknowledge there may be financial barriers for some members of our community in accessing programs for which there is fee. Please talk to staff if this is the case for you. We are committed to ensuring participation by all.