Hindmarsh Shire Council Youth Event Permission Form

I give permission for my son/daughter, to participate in the youth event being held at (insert location) ______on (insert date) ______under the supervision of Hindmarsh Shire Council staff, volunteers and designated leaders.

I understand that my son/daughter is to be on their best behaviour, and that I will be contacted to pick up my son/daughter, should their behaviour or actions render that necessary.

Youth Participant Information
Participant Name______
Participant Address______
Date Of Birth______Year Level ______
Travel Information (not available for all events, please see event promotional posters to confirm available transport options)
My child requires transport to and from this event. YES NO
Leaving from (insert location)______
And returning to (insert location)______
(Bus times and locations for pick up/drop off are subject to change depending upon the nature of each event. Please “like” the Hindmarsh Shire Youth Council Facebook page for regular updates)
Medical Information (Please tick if your child is living with any of the following health conditions)
 Asthma (if ticked complete Asthma Management Plan)
 Anaphylaxis (if ticked review and update the Individual Management Plan for the excursion)
 Blackouts  Diabetes  Dizzy spells  Migraine Allergies (Please List in other/care)
 Heart condition  Sleepwalking  Travel sickness  Fits/seizures of any type
 Other:______
Name of Family Doctor______Phone______
Address of family doctor______
Medicare Number______
Ambulance Cover Number______
Emergency Contact Name______Phone______
Is your child taking any medications? YES NO
If yes, please provide the name of the medication, dose, and describe when and how it is to be taken.
I authorise the Event Organisers to undertake all appropriate actions necessary in the event that my child requires medical attention. YES NO
Parent signature______Date______
Please initial next to one of the following statements:

Hindmarsh Shire Council has my consent to use my child’s photo on publications including but not limited to the Hindmarsh Shire Council webpage, Council newsletter, and/or social networking pages such as the Hindmarsh Shire Council and Youth Council Facebook pages.

Hindmarsh Shire Council may NOT use my child’s photo in any publications

Youth Name…………………………………… Youth Signature…………………………………… Date………………………….

Parent Name…………………………………. Parent Signature…………………….……………. Date………………………….

For further information and to book please contact:

Megan Hall

Youth and Early Years Officer

Hindmarsh Shire Council

Phone: 03 5391 4444 Mobile: 0418 121 187

Email:

****Please note all youth activities are drug, alcohol and smoke free. Any youth found to be in possession of an illicit substance will be referred to police.****

Please return this completed form in person C/O Meg Hall at your local Hindmarsh Shire Council office or via email to