Accounts Payable Officer

FORBES SHIRE COUNCIL SCHOOL HOLIDAY PROGRAM REGISTRATION FORM: APRIL 2015

Details Child’s Name: Gender: Male Female Date of Birth: Age: Home Address: Country of Birth: Language Spoken:

Please circle: Monday 6th Tuesday 7th Wednesday 8th Thursday 9th Friday 10th (13-17 years) (5-12 years) (5-12 years) (13-17 years) Public Holiday BMX ride & Short Remote control car Excursion Lake Excursion Orange Film workshop $10 racing & Skate Park Cowal Gold Cinema Insurgent excursion $20 Mine/BBQ Lunch (M) & Lunch @ provided $25 McDonalds (own money required) $25 Monday 13th Tuesday 14th Wednesday 15th Thursday 16th Friday 17th (5-12 years) (13-17 years) (13-17 years) (5-12 years) (5-12 years) Excursion Orange Games Day, Excursion Orange Excursion to Forbes End of holiday Cinema Home (PG) Remote control car Flip out & Lunch @ Health & Fitness/ice party/games/cooking & Lunch Adventure racing/ BBQ lunch KFC (own money cream @ $20 Park (bring own lunch) & computer room. required) $25 McDonalds & Craft $25 Youth Week Event activities $20 $10

Caregiver information – Parent/Carer Name/s: Home Address: Email Address: Home Phone Work Phone: Mobile Phone: Contact Numbers:

Home Phone Work Phone: Mobile Phone: Contact Numbers:

Excursions: I give permission for my child/children to participate in supervised excursions including trips out of town on bus and walks/visits to local parks/playground/shop as part of the Yes: program. I have indicated on registration form. I understand it is my responsibility to advise staff if I do not wish my child/children to participate in Yes: a particular activity. Transportation: My child/children has permission to be transported in a private vehicle if deemed Yes: necessary by the Holiday Program Coordinator or Council management. Exchange of Information: I give permission for the service staff to exchange information relating to appropriate person(s) (eg. In an emergency/special needs of my child/children) I understand Yes: that this information will be handled in confidenence). Photographic Consent: I give permission for photographs of my child/children to be taken and appear in promotional publications and/or all forms of media including social and that all photos Yes: taken are the property of Forbes Shire Council. Computer Consent: I give permission for my child/children to use the computers on the days Yes: they are enrolled? Panadol Consent: I give permission for the Holiday Program Coordinator to administer Panadol to your child if required and if we are unable to contact an emergency contact person for Yes: authorisation?

Forbes Shire Council | School Holiday Program Registration Form: April 2015 Version 2 – March 2015 (Doc Id: 249719) 1 of 2 FORBES SHIRE COUNCIL SCHOOL HOLIDAY PROGRAM REGISTRATION FORM: APRIL 2015

Accident & Illness: In the event of an accident or illness requiring emergency medical treatment every effort will be made to contact parents/emergency contact person before treatment is sought. Yes: However, should contact prove impossible, I give authority to Forbes Shire Council School Holiday Coordinator and staff for treatment to be undertaken? Please NOTE: if your child requires any medication to be administered at the program please ensure medication is in original packaging and up to date and medication/management plan and form is signed and provided. Medical/Emergency Procedures Please tick Immunisations received: Is your child Yes No Immunised? Birth 2mth 4mth 6mth 12mth 18mth 4 yrs 10 yrs Family Doctor’s Phone: Name: Do your child/children have any medical conditions/allergies etc? Yes: No: If so, please indicate any and provide management plans if required Allergies Skin Condition Asthma Epilepsy Diabetes ADHD/ADD

Other please state: Do your child/children have a disability or special need? Yes: No: Please provide information: Do your child/children have any physical/sensory impairments or challenging Yes: No: behaviours that Staff need to be aware of? Please notify staff on arrival. Is your child/children on any prescribed medications? (you will need to fill in an additional form if Staff are to administer these medications and hand Yes: No: medication to staff to store safely).

Applicant’s Declaration and Indemnity I hereby give consent for the child/children named above to attend the prescribed activities. I acknowledge that during participation in the activities my child/children will be exposed to the obvious risks associated with such activities. I indemnify Forbes Shire Council, its officers and agents and keep them indemnified against all claims, demands, actions and liabilities of any kind (other than due to wilful negligence) arising from my child/children’s participation in the activity. I authorise Forbes Shire Council staff, in the event of any accident or illness involving my child/children, to obtain such medical and hospital assistance as they believe may be required and agree to meet all expenses thereby incurred. I give permission for my child/children to attend any excursions programmed on the days they are enrolled. I have read and understood the Forbes Shire Council Holiday Program Behavioural Policy and understand that should my child/children not act in accordance with these expected levels they may be asked to leave the Centre and may be prevented from attending any future school holiday program.

I declare that the information I have provided on the above form is correct to the best of my knowledge. If any of the above information changes I will provide the relevant information on another enrolment form.

Privacy Statement The personal information provided in this document is protected under the Privacy and Personal Information Protection Act, 1998 (PIPPA). PPIPA provides for the protection of personal information, and for the privacy of individuals. Council must not disclose your personal information to any person or body if it is not directly related to the purpose for which the information was collected. If you require any further information about the collection and use of personal information, please contact Forbes Shire Council’s Privacy Officer on 02 6850 2300.

Signed ______Date: / /

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