Summer 2015 Youth School Holiday Program Permission Form

Young Person’s Details First Name______Surname______DOB ______Age: ______Home Address: Street ______Suburb______Postcode______State______Home Phone ______Mobile Phone______Parent / Legal Guardian Details Name of Parent / Guardian: ______Home Address (if different from young person) ______Suburb______Postcode______State______Home Ph ______Mobile Ph______Work Ph______Emergency Contact (Other than Parents/Legal Guardians list above) Name of Emergency Contact______Relationship to Young Person ______Home Address (if different from young person) ______Suburb______Postcode______State______Home Ph ______Mobile Ph______Work Ph______

If your child is subject to a custodial or domestic violence order, please inform a team member so a copy of such can be placed on file. Medical Details Does your child have any allergies and/or drug/food sensitivities? If YES please give details: ______Does your child has any medical conditions, disabilities or additional needs that employees need to be made away of? If so, please attach a copy of the treatment plan to this form______I give BCS permission to administer first aid to my child in the event of any emergency. This may include calling an ambulance, transporting to hospital, administering an asthma inhaler, etc. Yes / No I am aware that if my child is injured whilst out that I will incur the cost of them being transported to the hospital and anything else that may occur. This is a voluntary program that encourages social, emotional and skill development through youth participation and engagement. We are not a care service, however our team of experienced youth workers will supervise any young people who enter the space or participate in our activities. We take no responsibility for young people who chose to leave the company of our staff. By signing below, you are agreeing to these terms. Permission: For participants under 16yrs: ______Parent/Guardian Name ______Signature Date For participants over 16yrs: ______Young person’s name Signature Date

Please return to: The corner@bcs, Corner of Chandler St and Swanson Crt, Belconnen, P: (02) 6264 0200 F: (02) 6278 8109, E: [email protected] Out of Centre Excursions Bookings and permission notes are essential for all off-site excursions. Due to popular demand in recent School Holiday Programs, excursions will now be allocated via a preferential voting system. We will do our best to accommodate all preferences however dependent on demand we cannot guarantee that all preferences will be allocated.

Please number your preferences, 1 – 5 (you only need to preference the excursions you wish to attend)

BBQ and Sports in Park _____

Hoyts _____

Museum and Picnic _____

Zone 3 _____

Flip Out _____

Please note: The Flip Out Excursion requires an additional waiver form and this will also need to be completed and returned prior to the excursion. Please ask staff for this waiver form, if one is not attached.

Office use only Received by: ______Date received: ______