NurtureGroup Registration

All NurtureGroup registrations are subject to approval by Miracle Babies Foundation.

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

Yes

Which NurtureGroup location are you registering for?*

Your relationship to child/ren

Attending NurtureGroup

First Child's Birth Date

What gestation was Child 1 born at?

Did Child 1 stay in NICU or Special Care?

Yes

Which Hospital was Child 1 born at?

Second Child's Birth Date

What gestation was Child 2 born at?

Did Child 2 stay in NICU or Special Care?

Yes

Which Hospital was Child 2 born at?

Third Child's Birth Date

What gestation was Child 3 born at?

Did Child 3 stay in NICU or Special Care?

Yes

Which Hospital was Child 3 born at?

Fourth Child's Birth Date

What gestation was Child 4 born at?

Did Child 4 stay in NICU or Special Care?

Which Hospital was Child 4 born at?

Details of other children

Emergency Contact Details (for the attending Adult)

Family Circumstances

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

Yes

If yes, please specify

Dietary Requirements

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

Yes

If yes, please specify

Allergies: Please list any allergies your child/ren has

Medical: Please select any that apply

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*

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*

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

NurtureGroup Registration

Customer Details

Address Details

Additional Details

Attending NurtureGroup

Child 1

Child 2

Child 3

Child 4

Emergency Contact Details (for the attending Adult)

Family Circumstances

Dietary Requirements

Allergies

Medical

Audio Visual Consent

NurtureLine
1300 622 243

NurtureGroup Registration

Customer Details

Address Details

Additional Details

Attending NurtureGroup

Child 1

Child 2

Child 3

Child 4

Emergency Contact Details (for the attending Adult)

Family Circumstances

Dietary Requirements

Allergies

Medical

Audio Visual Consent

NurtureLine 1300 622 243

NurtureLine
1300 622 243