Children and Youth Services

PROGRAM ENROLMENT FORM

Your Child’s Details

Name
Date of Birth
Age
Address
Phone Number

Emergency Contact Information

Please ensure the following contacts are available on the phone numbers that you have provided on the dates of the program.

Primary Emergency Contact

Name
Relationship to Child
Home Phone Number
Mobile Phone Number
Work Phone Number

Secondary Emergency Contact

Name
Relationship to Child
Home Phone Number
Mobile Phone Number
Work Phone Number
I give consent for my child to participate in the following activities.
Please indicate “Yes” next to the activity your child is attending
Junior Sleepover/Fun Club Day
Senior Sleepover/Fun Club Day
SALSA Camp
Other Program (please specify)

Medical Information Form

Please tick the box below that best describes your situation:
I require a new Annual Medical form as my child’s details have changed. (Note; If this is the first activity your child is attending for 2018, you are required to fill in a new medical information form). / YES / NO
I have completed the 2018 Medical Information Form. My child’s details, medical conditions, and requirements have not changed. / YES / NO
If you require a new annual Medical Information Form, please indicate if you would prefer us to post or email a new form to you:
Post a Medical Information form to:
Email a Medical Information form to:

My Child’s Car Seat

Note: If your child is not legally required to be transported in a car seat, please disregard the following
I give permission for VisAbility staff to install and secure my child’s car seat, in VisAbility vehicles / YES / NO

Terms of Participation and Agreement

Please read the following terms carefully before signing this form.

  • I agree to inform CAYS Staff before the holiday program event of any changes to my child’s health and fitness so that appropriate supervision can be arranged
  • I give permission for my child to be transported by VisAbility staff members and volunteers, both by VisAbility vehicles and private vehicles, should the need arise
  • Any loss or damage to my child’s personal property that may occur during the course of the programs and activities is not the responsibility of VisAbility or VisAbility’s staff
  • I acknowledge that VisAbility is not responsible for any loss or damage to my child’s mobile phone or the costs of any phone services occurred during programs and activities
  • I am aware that tobacco based products, alcohol and other illegal substances and associated paraphernalia ARE NOT permitted at VisAbility programs and activities, any child found to be in possession of such items will be sent home immediately
  • I understand that supervising staff may need to perform bag and clothing searches
  • I agree to delegate my authority to supervising staff. Such staff may take whatever disciplinary action they deem necessary to ensure the safety, wellbeing and successful conduct of the participants as a group and individually in-line with VisAbility’s policies
  • I am aware my child may be sent home with no refund or reduction in the fee payable if they: wilfully leave VisAbility Perron Centre or group while out, damage or deface property, or if their conduct or influence is detrimental to the best interests of the activities and or other children
  • In the case of cancellation or “no show” following the RSVP date, VisAbility will charge a cancellation fee as per funding guidelines (up to 1 hour per day).
  • In the case of purposeful damage by my child, I accept that I may be billed for the full cost of the damage and possible costs accrued due to the damage
  • In the case of late arrival, dismissal or withdrawal of my child, there will be no refund of the activity fees for the time remaining
  • In the event that my child is sent home due to illness or accident or upon the instruction of medical staff, refunds will be considered
  • I understand that some of the activities may include certain inherent risks and VisAbility will put in places steps to reduce any perceived risks

Confirmation

By signing this enrolment form I,

  • Agree to the terms of participation in the above-mentioned program or activity
  • Have to the best of my knowledge, provided all accurate medical information pertaining to my child

Name of Parent/Legal Guardian
Signature of Parent/ Legal Guardian*
(scanned copy of handwritten signature is accepted)
Date

This form must be completed for every VisAbility CAYS activity your child attendsPage 1 of 3