Carnarvon Inclusive School

Holiday Program – July 2015

REGISTRATION - PARTICIPANT’S INFORMATION
Participant’s Name(s): / Age(s): / Gender: M/F / School:
Does/Do your child/children have a disability?
Is/Are your child/children of Aboriginal or Torres Strait Islander origin?
Does/Do the participant/s currently belong to a local sport/rec. club? If yes, which club?
EMERGENCY CONTACT INFORMATION
Name: / Relationship:
Email: / Contact No.:
VISUAL IMAGES RELEASE FORM
The main aim of our promotions is to increase awareness of our programs to clients, promote success stories and attract volunteers. To do this we develop posters, brochures, a website and a quarterly newsletter that include descriptions of our programs with positive visual images.
Although Inclusion WA will endeavor to ensure accuracy, Inclusion WA cannot be held responsible for any use or misuse of the images once released.
Please tick this box if you DO give permission to Inclusion WA / Youth Outreach to utilize photographic and/or visual images in promotional resources for the purposes outlined above.
Please tick this box if you DO NOT give permission to Inclusion WA / Youth Outreach to utilise photographic and/or visual images in promotional resources for the purposes outlined above.
WAIVER AND GENERAL RISKWARNING
As a parent/guardian of a participant in this recreational activity program, I accept that my child/children may be exposed to a risk of harm or injury.
I confirm that my child/children have the ability to swim unassisted and acknowledge that water based activities may occur. I understand that Inclusion WA and/or the host organisation will take all possible care for my child/children's well-being, and that whilst my child/children is/are participating in this activity, Inclusion WA staff will make every reasonable effort to minimise exposure to known risks. However, I also understand my child/children has/have a personal responsibility to follow general safety measures.
I therefore accept full responsibility for my child’s safety and well-being from the moment they enter the premises, or take part in the activity and I agree that if they suffer injury or illness, Inclusion WA and/or the host organisation can, at my cost, arrange medical treatment as the staff or leaders deem essential for my child’s safety.
By signing this form, I voluntarily agree to release and hold harmless Inclusion WA and/or the host organisation, its Board of Management, volunteers, assistants and employees for any damage or injuries, physical or mental, which I might incur as a result of my voluntary decision for my child to participate.
Signed: / Date:
SESSION PARTICIPATION
*Please tick boxes below if your child will be attending programmed sessions*
My child won’t be attending ☐ / We will be away for the holidays ☐ / We are not interested ☐
Week 1 / Week 2
Monday 6/7/15
NAIDOC OPENING CEREMONY
9.30am March from town beach to Cultural Centre / Morning Session 1 ☐
Tuesday 7/7/15 / Tuesday 14/7/15
Fishing
Fascine Foot Bridge
10.30am – 12.00pm / Morning Session 1 ☐ / Carnarvon Space and Technology Museum
9.30am -11.30am
Limited to 15 participants
$5 Kids
$7 Adults / Morning Session 1 ☐
Wednesday 8/7/15 / Wednesday 15/7/15
Kangaroo Trial
Athletics
10am- 2pm
Contact Mel 0419 726 066
MOVIE Tomorrow land PG
2pm- 4.30pm
$5
Carnarvon Civic Centre / Morning Session 1 ☐
Afternoon Session 2 ☐ / MOVIE HOME PG
2pm -4.15pm
$5
Carnarvon Civic Centre / Afternoon Session 1 ☐
Thursday 9/7/15 / Thursday 16/7/15
Netball
9am-11am
Netball courts festival grounds
Contact Ainslee
0400 206 732 / Morning Session 1 ☐ / Zorb Ball / Games Day
Festival Grounds
10.30am – 12.00pm / Morning Session 1 ☐
Friday 10/7/15 / Friday 17/7/15
Pony Club
Limited numbers 15 youth
Please fill in pony club permission form.
(9am-11am)
Contact Ainslee
0400 206 732 / Morning Session 1 ☐ / Disco
PCYC
(6pm-8pm)
Entry $3
Canteen on the night
Contact PCYC 9941 4116 / Evening Session 1 ☐
** WOULD YOU LIKE TO BE INVOLVED? ** - VOLUNTEER REGISTRATION
Name: / Phone:
The activity you would like to help with:
Do you have any specific skills or ideas to apply to the program in the future?
Would you like to be a part of the planning group for the holiday program?
Please note: Coaches/Volunteers are responsible for instruction and group supervision. Carer support may be required for participants requiring one to one assistance with activities or equipment. Parents/Guardians are encouraged to participate for the duration of the session where possible.
Matt: 0437 714 318 –

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