Mercury Bay Blue Light – Youth Enrollment Form Download PDF Version Here Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Participant DetailsFull Name *FirstLastPreferred Name *Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of School * (if Support Behaviour Address *Address Line 1CityState / Province / RegionPostal CodePhone *Email *Parent/Guardian InformationName *FirstLastPhone *Email *Address (if different)Address Line 1CityState / Province / RegionPostal CodeEmergency ContactName *FirstLastRelationship *Phone *Medical & Support InformationDetails (allergies, conditions, support needs): *Doctor / Medical Centre: *Phone *Consents (Tick One)Participation *YesNoTransport: *YesNoPhoto/Media: *YesNoCode of Behaviour AgreementI agree to follow the Mercury Bay Blue Light Code of Behaviour.Participant Signature: * Clear Signature Date: *Parent / Guardian ConsentI confirm the information is correct and consent to participation.Name *FirstLastParent Signature: * Clear Signature Date: *Office Use OnlyDate Received & Staff Member:Submit
