WINTER2016 - PARTICIPANT CONSENT FORM
SECTION A: YOUNG PERSONS DETAILS
Please complete the following details for the young person attending the program.
Full Name:Date of Birth: / / Sex: Male Female
Mobile Phone:
Email:
Address:
Suburb:Postcode:
School (if relevant):
Medicare Number:Personal ID on Medicare Card:Expiry Date:
SECTION B: MEDICAL INFORMATION
Please ensure that you complete ALLsections of the form, even if the young person has previously attended this program.
Does the young personsuffer from any asthma or allergies? Please tick all that apply. Asthma Allergy Anaphylaxis
Details: ______
Note: If you answered yes to either Asthma or Anaphylaxis you MUST provide a copy of an Anaphylaxis or Asthma management plan with your booking.
Is the young person required to take any medicationsduring the time of the activity? Yes No
Details: ______
Does the young person require additional support to participate in the program? Yes No
(If yes, a staff member will contact you to further discuss the support required.)
Details: ______
Is the young person a current client of Yarra Ranges Council Aged & Disability Services? Yes No
Does the young person have any relevant medical conditions (eg: allergies, epilepsy, diabetes, travel sickness, mental health issues, etc)? Yes No
Details: ______
Is there any further information that staff should be aware of (eg: dietary requirements, behavioral issues, social issues, learning difficulties etc)? Yes No
Details: ______
Do any custody or access arrangements apply? Yes No
If yes, please provide details here and where relevant please provide a copy to staff.
Details: ______
GENERAL PERMISSIONS
Do you give permission for your young person to sign themselves in and out of the program?
All young people participating in Youth Services programs may be photographed for the purpose of documenting and promoting activities. Do you provide consent for photographs of your child to be used on publicity flyers, brochures, social media, articles/advertisements in newspapers, as well as on the Youth Services website?
Would you like to join the Youth Services mailing list for information about upcoming programs and events? / Yes No
Yes No
Yes No
PRIVACY STATEMENT: Personal and or health information collected by council is used for the purpose of conducting the school holiday program. The personal and/or health information will be used solely by council for this purpose and or directly related purposes. Council may disclose this information to other organisations if required by legislation. The applicant understands that the personal and or health information provided is for the above purpose and that he or she may apply to council for access to and or amendment of the information. Requests for access and or correction should be made to Council’s Privacy Officer.
SECTION C: PARENT/GUARDIAN DETAILS
Please complete the following details for the parent/guardian responsible for booking (if the participant is under 18 years of age).
Full Name: Relationship to participant:
Contact numbers (home/work): (mobile)
Email:
SECTION D: Emergency Contacts
Please nominate TWO people over the age of 18 years to be contacted in case of emergency. These two people should not be the same as the person listed in Section C. The people listed as emergency contacts must be able to collect the young person if required.
Emerency Contact 1:
Full Name: Relationship to participant:
Contact numbers (mobile): (home/work):
Emerency Contact 2:
Full Name: Relationship to participant:
Contact numbers (mobile): (home/work):
PARENT/GUARDIAN AGREEMENTThis section is to be signed by the parent/guardian if the young person participating is under 18.
If 18 years or older, this section is to be signed by the participant.
Please check through this form to ensure every question has been answered. Should you have any queries please call Yarra Ranges Council on 9294 6716. Once fully completed, please read and sign the agreement below to allow your enrolment application to be processed.
I, ______(insert Parent/Guardian name in BLOCK CAPITALS)
Permit my young person to attend the Yarra Ranges Council Youth School Holiday Program and participate in the activities organised for the days my child will be attending.
Agree that where I have provided insufficient information regarding the participant’s health and needs, that an assessment may be carried out to determine the program suitability for my child.
Authorise staff, in the event of an accident or illness, to obtain all necessary medical assistance and treatment for my child/renincluding where deemed necessary transport to hospital by ambulance.
Agree that, the Yarra Ranges Council, and their Officers are free and clear of all responsibility whatsoever for accident, illness, theft/loss of clothing or valuables during my child’s participation on any of the activities involved in the program.
Agree that Council, and their officers will not accept responsibility for injuries sustained by my son/daughter during attendance at this activity, in particular those activities resulting from behavior contrary to the direction of Council officers and services.
Accept that I would come to the activity to collect my child or cover any associated expenses, in the case of an emergency/illness or due to unacceptable behavior.
Acknowledge that a refund will only be offered to bookings cancelled 7 days prior to the activity. In the event of illness/emergency on the day of the activity, credit will be provided for the following holiday program provided that I endeavour to notify the program coordinator as soon as possible by calling 9294 6825.
Agree that, I will provide all changes to the personal and medical information provided onthis enrolment form in writing as required and without delay.
Confirm that the above information I have provided on this form is correct.
Please note that transport and activities may be changed or cancelled in the event of extreme weather conditions.
Yarra Ranges Council will contact all participants to inform them if this should occur.
Parent/Guardian Signature ______Date:______
YOUNG PERSON AGREEMENT
I, the undersigned, agree to abide by the following rules when participating in youth activities with Yarra Ranges Council:
- No smoking, alcohol or drug use.
- We have a strict no bullying policy. No offensive, abusive or inappropriate behaviour &/or language will be tolerated.
- All safety guidelines and procedures, in particular on transport, must be obeyed.
- Participants are to remain with the group at all times and will not be permitted to leave the activity early except with prior written permission from parent/guardian.
- Instructions from staff must be followed at all times.
- Failure to abide by the above rules, may mean that I am asked to leave an event before it has ended. Any costs involved will be at my, or my parent/guardian’s, expense.