High School Club Application Form Club Application Participant's Name * Date of Birth School School Year Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Mother's Name * Father's Name Home Phone Parent's Work Phone Parent's Mobile Phone Address * Email * Medicare Number Details of private health insurance/ambulance cover (if any) Does your daughter suffer from any allergies? * Yes No Please provide details of allergies and management plan below: Does your daughter suffer from any medical conditions? * Yes No Please provide details of medical conditions and management plan below: Does your daughter have any dietary requirement? * Yes No Please provide details of dietary requirements: Consent Form This consent form allows your daughter to participate in the activities conducted by Lowana. It also allows Lowana to use your daughter's images, photographs, videos for Lowana's promotions and advertisements. consent form Please download this consent form and either: 1) e-mail it to firstname.lastname@example.org OR 2) ask your daughter to bring it with her to the club. Payment Please pay this by direct debit by week 4 of each term into the following account: Lowana Club Account BSB: 032273 Account No: 295568 Remittance: Last name and year level Please select payment option: * 1 child/term - $60 1 child/year - $220 (paid in term 1) 3 children /term - $150 3 children /year - $560 (paid in term 1) Please list name and school years of all children included in payment: reCAPTCHA Submit If you are human, leave this field blank.