NurtureGroup Rego Form - Miracle Babies

Last Name *

Email *

Phone *

Mobile *

Address Details

Address 1 *

Suburb *

State *

Postcode *

Additional Details

Have you experienced the birth of a premature or sick newborn? *

Yes

No

How did you hear about NurtureGroup? *

Which NurtureGroup location are you registering for? *

Over the last week how would you rate your emotional wellbeing? *

Your relationship to child/ren *

Attending NurtureGroup

Number of Children *

Child 1

First Child's Name *

First Child's Birth Date *

What gestation was Child 1 born at? *

Did Child 1 stay in NICU or Special Care? *

Yes

No

Which Hospital was Child 1 born at? *

Child 2

Second Child's Name

Second Child's Birth Date

What gestation was Child 2 born at?

Did Child 2 stay in NICU or Special Care?

Yes

No

Which Hospital was Child 2 born at?

Details of other children

Emergency Contact Details (for the attending Adult)

Name *

Contact Number *

Relationship *

Family Circumstances

Family Circumstances: Are there any situations we should be aware of (Eg. Custodian issues, other matters), *

Yes

No

If yes, please specify

Dietary Requirements

Dietary Requirements: Do the attendees have any dietary requirements? *

Yes

No

If yes, please specify

Allergies

Allergies: Please list any allergies your child/ren has. Put N/A if there are none. *

Medical

Medical: Please select any that apply (please select N/A if there are none) *

If other, please list

I authorise the use of an Ambulance and/or anaesthetic by a qualified medical practitioner if in his/her judgment it is necessary and accept responsibility for payment of all expenses associated with such treatment *

Yes

No

In case of emergency I authorise the NurtureGroup Coordinator to arrange medical treatment as deemed necessary during NurtureGroup and accept responsibility for payment of all expenses associated with such treatment *

Yes

No

Audio Visual Consent

I consent to be videotaped, audio recorded and/or photographed during the attendance of a Miracle Babies Foundation event or promotion. I understand and agree to the video, audio recording or photographs being taken used for Miracle Babies Foundation *

yes, just myself

yes, myself and/or my partner and children

No

NurtureLine 1300 622 243

NurtureLine
1300 622 243