School Holiday Program

Sep/Oct 2013

School Holiday Program

Permission Slip

Name / Cultural Background
Date of Birth / Age

√ Please tick the excursion/s you want to attend:

Tues:24/09 / OPEN DAY / FREE
Wed: 25/09 / LUNA PARK / $35
Thurs: 26/09 / STRESS LESS FEST / FREE
Mon: 30/09 / ROCK CLIMBING / $5
Tues: 01/10 / ICE SKATING / $15
Wed: 02/10 / AEROSOL ART / FREE
Thurs: 03/10 / AEROSOL ART / FREE

Parent/Guardian contact information (if needed in an emergency)

Address / Number/Street / Suburb/Postcode
Name of Contact Person / Parent/Guardian/Youth Worker(please circle)
Phone Numbers
(in case of emergency)
In the case that you cannot be contacted, please provide an alternative contact / Home:
Work:
Mobile:
Alternative contact: Number:
Email / (If you would like to be kept up to date with MYRC activities)
Medicare
number of
young person
Food allergies,
special dietary requirements (please be specific)
Behaviour:
(Any behavioural challenges we need to be aware of?)

Please see the other side

*If the young person has a disability or high needs that may impact on managing or caring for the young person/s attending you must speak to MYRC Director to ensure these needs can be met*

*All information collected by MYRC is generally kept private and you may ask for a copy of MYRC privacy policies if you wish*

I give the above mentioned, permission to attend and be transported to and from the following activities organised by Marrickville Youth Resource Centre (MYRC). I understand that all activities depart & arrive at MYRC unless stated otherwise and that young people are supervised by at least 2 workers on all activities, and that at least one of these staff members will be a certified senior first aid officer.

I understand that all reasonable care for the safety and health of the young person in care of MYRC will be taken by the person in charge. In the event of an illness or accident occurring to the young person during an activity I will be notified as soon as possible. In the event that I cannot be contacted, I authorise the person in charge to consent to the young person receiving such medical and/or surgical treatment (including the administration of anaesthetic) as may be deemed necessary by a legally qualified medical practitioner.

I also understand that photos may be taken during activities and used for promotional purposes (please state if you do not wish to have photographs taken).

I understand that if the young person attending an activity appears to be under the influence of alcohol or other drugs I will be called to pick up the young person immediately. And that this may jeopardise the young person in care of MYRC attending future activities with MYRC.

I agree that young people will be subject to the directions and control of MYRC staff and are expected to obey reasonable rules governing safety and behaviour. And that if the young person in care of MYRC cannot obey these rules and directions I will be called to pick the young person immediately.

If the young person in care of MYRC leaves the group or fails to return I will be contacted immediately and I will instruct MYRC staff on what course of action I would like them to take.

I agree that MYRC will not take responsibility for personal possessions lost during activities. And lending or borrowing is the responsibility of the young person in care of MYRC.

Name: ______Name of Organisation/Service: ______

(Parent /Guardian/Carer)

Signature: ______Date: ____/____/____