Section 3 - Registration for Children under the age of 16 NOTE: It is optional to supply information in sections of this form marked with asterisks* 1 Child 2 Given Name/s Given Name/s Family Name Family Name Other Name/s Other Name/s / / / / Date of Birth Date of Birth Gender Male Female Gender Male Female *Is the child of Yes - Aboriginal *Is the child of Yes - Aboriginal Aboriginal or Yes - TSI Aboriginal or Yes - TSI Torres Strait Yes - Aboriginal/ TSI Torres Strait Yes - Aboriginal/ TSI Islander origin? No Islander origin? No - - Medicare Number Medicare Number I am the child’s: Your relationship Your I am the child’s: to this child relationship to this child OFFICE USE HRN HC OFFICE USE HRN HC Child 3 Child 4 Given Name/s Name/s Family Name Family Name Other Name/s Other Name/s / / / / Date of Date of Birth Gender Male Female Gender Male Female *Is the child of Yes - Aboriginal *Is the child of Yes - Aboriginal Aboriginal or Yes - TSI Aboriginal or Yes - TSI Torres Strait Yes - Aboriginal/ TSI Torres Strait Yes - Aboriginal/ TSI Islander origin? No Islander origin? No - - Medicare Number Medicare Number I am the child’s: Your relationship Your I am the child’s: to this relationship to this child OFFICE USE HRN HC OFFICE USE HRN HC Child 5 Child 6 Given Name/s Given Name/s Family Name Family Name Other Name/s Other Name/s / / / / Date of Date of Birth Gender Male Female Gender Male Female *Is the child of Yes - Aboriginal *Is the child of Yes - Aboriginal Aboriginal or Yes - TSI Aboriginal or Yes - TSI Torres Strait Yes - Aboriginal/ TSI Torres Strait Yes - Aboriginal/ TSI Islander origin? No Islander origin? No - - Medicare Number Medicare Number to this child Your relationship
Section 3 - Registration for Children under the age of 16 NOTE: It is optional to supply information in sections of this form marked with asterisks* 1 Child 2 Given Name/s Given Name/s Family Name Family Name Other Name/s Other Name/s Date of Birth / / Date of Birth / / Gender Male Female Gender Male Female *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No Medicare Number - Medicare Number - Your relationship to this child I am the child’s: Your relationship to this child I am the child’s: OFFICE USE HRN HC OFFICE USE HRN HC Child 3 Child 4 Given Name/s Name/s Family Name Family Name Other Name/s Other Name/s Date of / / Date of Birth / / Gender Male Female Gender Male Female *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No Medicare Number - Medicare Number - Your relationship to this I am the child’s: Your relationship to this child I am the child’s: OFFICE USE HRN HC OFFICE USE HRN HC Child 5 Child 6 Given Name/s Given Name/s Family Name Family Name Other Name/s Other Name/s Date of / / Date of Birth / / Gender Male Female Gender Male Female *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No *Is the child of Aboriginal or Torres Strait Islander origin? Yes - Aboriginal Yes - TSI Yes - Aboriginal/ TSI No Medicare Number - Medicare Number - Your relationship to this child
Consumer%20Registration%20Form.docx