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Stride Kids – registration & consent form

Introduction to the Stride Kids.

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All are welcome

Once you have filled in this form, the information will be sent through to our administration, and they will contact you for a phone appointment with one of our Clinicians.

Stride Kids – registration & consent form

"*" indicates required fields

Participant Details

“*” indicates required fields
DD slash MM slash YYYY
Gender*
Are you Aboriginal, Torres Strait Islander or South Sea Islander?*

Education

Please Tick Highest Level of Education

Medical

Do you authorise for staff at Stride Kids to administer first aid or contact emergency services if required?

Emergency Contacts

In the event of an emergency, I consent to Stride Kids advising the following people:

Consent of Service

Disclosure of Liability of Healthcare and Parental Authority for the Treatment of a Minor (not applicable if the participant is over 18 years old)
Stride Kids is committed to ensuring the rights, responsibilities and actions associated with service provision, and will fully explained this to all children and carers. When engaging with Stride Kids, carers will be asked to indicate their informed consent, that is consent that is given freely, without concern threats, or improper inducements.
Guardian Declaration*
DD slash MM slash YYYY
With this legal responsibility, I give Stride permission to establish a treatment plan for the benefit of my child’s health and wellbeing.
Stride only requires the consent of one parent per child, in particular, when providing services to children of separated parents. The consent of either parent is sufficient authority for a doctor or other health professional to deliver care. Parents are also entitled to refuse treatment that a doctor recommends or choose alternative treatment.

Consent to Share Information

The people and services that I agree to share my information with are:
The people and services that I do not agree to share my/my child’s information with are*
DD slash MM slash YYYY
Clear Signature
Please know that consent to any of the above can be changed or withdrawn at any time, however, please know that if you withdraw consent for your child to engage, we will not be able to provide any services. If you have any questions or concerns, please talk with a Stride Kids team member.