Holiday Action Enrolment Form

SCHOOL HOLIDAY ENROLMENT FORM Youth Services Mildura |  (03) 5018 8280 | [email protected]

Young Person’s Details

First name: Last name: Preferred name:

Address: Suburb:

Postcode: Email:

Age: Date of birth: Gender:  M  F  (mobile):

What secondary school does the young person attend? Parent or Guardian Details

Relationship to young person:  Parent  Grandparent  Guardian / Carer  Worker

Other:

First name: Last name:

 (mobile):  (home):

Is your address the same as the young person’s?  Yes  No (if no, complete the following)

Address:

Suburb: Postcode: Emergency Contact

First name: Last name:

Relationship:  (mobile): Picking up the Young Person (who is authorised to collect the young person, other than the parent or guardian?) Full name: Full name:

Relationship: Relationship:

 (mobile):  (mobile): Family Arrangements

Are there any custody arrangements?  Yes  No (if yes, please photocopy and attach to this form) Health and Wellbeing

To create an opportunity for the young person to have an enjoyable experience in the program, could you please indicate if any of the following apply?  Disability  Asthma  Allergies  Epilepsy  Medication

 Additional or complex needs  Other medical condition  Behavioural issues

 (If yes, please provide Dietary requirements details) ______Supervision The young person is allowed to leave the Scout Hall by themselves at the end of the activity. Leaving the program  Yes  No

The young person requires constant staff supervision. Constant supervision  Yes  No

Do you allow for photographs / video footage to be taken of your young person during programs and also acknowledge that any photographs taken will be stored in Council’s photographic library and will be used and disclosed to all Council staff, contractors and suppliers involved in the designing, publishing and printing Photographs of Council publications and other editorial material for distribution to the general public? Do you further acknowledge that you will immediately advise Council should your circumstances change or should you wish to revoke your consent?  Yes  No

Please indicate the young person’s swimming ability: Swimming  Non swimmer  Basic  Experienced

What rating do you approve the young person viewing in a movie or video? Movie rating  PG  M  MA  MA 15+

Activity Details

Date Activity Price Time  Cost

1 Thursday 12 January Laserforce $15.00 8.30am – 3.30pm 

‘Fun in the Sun’ – Outdoor 2 Friday 20 January Pool Challenge @ Irymple Free 8.30am – 3.30pm  Pool

Participants are to meet at the front of the Roxy Theatre. The bus will depart from Roxy Theatre 8.30am SHARP for Mildura and returning to Ouyen approximately TOTAL $ 3.30pm.

I, ______(Insert Parent/ Guardian Name in BLOCK CAPITALS if written)  Agree to the participation of the abovementioned young person in Mildura Rural City Council School Program activities.  Agree that I have read and understand the School Holiday Guidelines.  Confirm the above information I have provided on this form is true and correct.

______(Parent/ Guardian Signature) (Date)

Privacy Notification Mildura Rural City Council collects personal and or health information for municipal purposes as specified in the Information Privacy Act 2000. The information collected in this form is used only for the purposes specified (primary purpose) and is not passed on to third parties. Council may disclose this information but only if authorised or required by law. Council may not be able to process your request unless sufficient information is given. Should you need to change or access your personal details, or you require further information regarding Council’s Privacy Policy, please contact Council’s Privacy Officer.