Child and Family Services

INFANT Program Registration Form

The Child and Family Team at Access Health and Community (AccessHC) is excited to be working with your Maternal and Child Health Nurses to offer you the INFANT program. INFANT is designed to support parents and families with health eating and active play from the start of their baby's life, with group sessions designed to support milestones at 3 months, 6 months, 9 months and 12 months.

Which site would you like to attend the program at? *

LilydaleUpwey

Parent Details

Parent First Name: *

Parent Surname: *

Parent Gender: *

Parent Date of Birth: *

Home Address *

Email address: *

Home phone number:

Mobile phone number: *

Preferred Language *

Does the attending parent have any known allergies? *

No known allergiesYes

Please describe allergies: *

Child's Details

Child's First Name *

Child's Surname *

Child's Gender: *

Child's Date of Birth: *

Does the child have any known allergies? *

No known allergiesYes

Please describe child's allergies *

Is the child up to date with immunisations? *

YesNo

Please attach a copy of immunisation statement

Browse

Please describe any medical details our team should be aware of:

Emergency Contact Person

(Please enter details of a person who is NOT the attending parent)

First Name: *

Surname: *

Relationship to Child *

Address:

Phone number: *

Consent

AccessHC requires your details and consent for the purpose of this program only.

Please see our Rights and Responsibilities flier here: Rights and Responsibilities

Please see our Privacy Policy Statement here: Privacy

I consent for AccessHC to share information with my Maternal Child Health Nurse *

YesNo

Maternal Child Health Nurse name *

Address *

Phone *

I consent to registration at Access Health and Community to enable my attendance at the INFANT program. *

Signature *

Draw signature|Type signatureClear

Parent / Guardian / Carer name *

Date *