YOUTH SERVICES INTAKE FORM

Young Person’s Details
First name: / Last name: / Preferred name:
Address: / Suburb:
Postcode: / Email:
Age: / Date of birth: / Gender: / M  F /  (mobile):
What secondary school does the young person attend?
Cultural
Are you of Aboriginal or Torres Strait Islander descent?  Yes  No
Language/s spoken: / Cultural background:
Do you require an interpreter?  Yes  No
Parent or Guardian Details (complete if the young person is under 18 years)
Relationship to young person: /  Parent  Grandparent  Guardian/Carer  Worker
Other:
First name: / Last name:
 (mobile): /  (home):
Is your address the same as the young person’s? /  Yes  No (if no, complete the following)
Address:
Suburb: / Postcode:
Emergency Contact
First name: / Last name:
Relationship: /  (mobile):
Picking up the Young Person (who is authorised to collect the young person if under 18 years, other than the parent or guardian?)
Full name: / Full name:
Relationship: / Relationship:
 (mobile): /  (mobile):
Family Arrangements
Are there any custody arrangements? /  Yes  No (if yes, please photocopy and attach to this form)
Responsibilities and Expectations for the Young Person and Mildura Rural City Council
  • Field trips are part of the program delivery and will operate under normal supervision and program guidelines. They may involve walking or being transported by Council buses / cars to venues inside the municipality.
  • Excursions are part of program delivery and will operate under normal supervision and program guidelines. They may involve walking or being transported by Council buses / cars to venues inside and outside the municipality.
  • The minimum supervision ratio is one program staff member to 15 young people with two staff being present at all times.
  • Staff will obtain medical assistance as required and medical expenses will be met by the parent or guardian.
  • The young person will conform to standards of behaviour and safety and if they do not adhere to these conditions, the parent / guardian will collect the young person from the program, fieldtrip or excursion or the young person will be returned home at the parent’s / grandparent’s / guardian’s / worker’s expense and further participation may be denied.
  • Equipment that is damaged as a result of the young person will be repaired or replaced at the parent’s / guardian’s expense.
  • Refunds will only be given if 24 hours notice and a doctor’s certificate are both provided.
  • Mildura Rural City Council may cancel activities due to circumstances beyond their control.
  • Mildura Rural City Council and its staff members are free and clear of all responsibilities and liabilities whatsoever of any accident or illness to the young person and damage, loss and or theft to personal property incurred during participation in the delivery of a service or program and connected activities.

Sharing your Information
Youth Services at Mildura Rural City Council are collecting this personal, sensitive and health information to:
  • Ensure young people are supported during specific program and general service delivery.
  • Ensure parents / grandparents / guardians / workers or emergency contacts can easily be contacted if required.
  • Assist Youth Services with strategic program and service planning, delivery and evaluation.
  • Create an opportunity to provide you with promotional material about the services and programs.
All emergency contacts listed have been notified and have given permission for their details to be provided.
The information may be used if there are any unlawful actions or behaviours from the young person.
How your Information will be Used
The personal, sensitive and health information collected will be used by Youth Services within Mildura Rural City Council for the primary purposes stated above or a directly related purpose. The information you provide shall remain private within Council unless disclosure is required by law, or consented to by you. You may apply for access and / or amendment of the information by writing to the Mildura Rural City Council Privacy Officer.
Agreement on your Responsibilities and Information
  • Provide permission for the young person to attend the Mildura Rural City Council program or service.
  • Accept the conditions noted in the section for ‘Responsibilities and Expectations’ and I have read and explained the conditions to the young person (if under 18 years) and they also understand and accept these conditions.
  • Consent to the collection and use of information and privacy statements as noted in the ‘Sharing your Information’ section.
  • Consent to the statement as noted in the ‘How your information will be Used’ section.

I, / (name) the parent / grandparent / guardian / worker of
(young person’s name), hereby sign
(signature) to state my acceptance and consent to the points outlined above on / (date).
Health and Wellbeing
To create an opportunity for the young person to have an enjoyable experience in the program, could you please indicate if any of the following apply?
 Disability /  Asthma /  Allergies /  Epilepsy /  Medication
 Additional or complex needs /  Other medical condition
 Dietary requirements / (if yes, please detail)
Supervision (complete if the young person is under 18 years)
Leaving the program / The young person is allowed to leave the program or excursion alone?
 Yes  No
Constant supervision / The young person requires constant staff supervision?
 Yes  No
Photographs / Do you allow for photographs / video footage to be taken of your young person during programs and also acknowledge that any photographs taken will be stored in Council’s photographic library and will be used and disclosed to all Council staff, contractors and suppliers involved in the designing, publishing and printing of Council publications and other editorial material for distribution to the general public? Do you further acknowledge that you will immediately advise Council should your circumstances change or should you wish to revoke your consent?
 Yes  No
Swimming / Please indicate the young person’s swimming ability:
 Non swimmer  Intermediate  Experienced
Movie rating / What rating do you approve the young person viewing in a movie or video?
 PG  M  MA  MA 15+
Privacy Notification
Mildura Rural City Council collects personal and or health information for municipal purposes as specified in the Information Privacy Act 2000. The information collected in this form is used only for the purposes specified (primary purpose) and is not passed on to third parties. Council may disclose this information but only if authorised or required by law. Council may not be able to process your request unless sufficient information is given. Should you need to change or access your personal details, or you require further information regarding Council’s Privacy Policy, please contact Council’s Privacy Officer.

Mildura Rural City Council

Youth Services | 78 Pine Avenue | Mildura

 5018 8280 |

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