SCHOOL HOLIDAY ENROLMENT FORM

Youth Services Mildura | ( (03) 5018 8280 |

Young Person’s Details
First name: / Last name: / Preferred name:
Address: / Suburb:
Postcode: / Email:
Age: / Date of birth: / Gender: / 5 M 5 F / ( (mobile):
What secondary school does the young person attend?
Parent or Guardian Details
Relationship to young person: / 5 Parent 5 Grandparent 5 Guardian / Carer 5 Worker
Other:
First name: / Last name:
( (mobile): / ( (home):
Is your address the same as the young person’s? / 5 Yes 5 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? / 5 Yes 5 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?
5 Disability 5 Asthma / 5 Allergies / 5 Epilepsy / 5 Medication
5 Additional or complex needs / 5 Other medical condition / 5 Behavioural issues
5 Dietary requirements / (If yes, please provide details) / ______
Supervision
Leaving the program / The young person is allowed to leave the Scout Hall by themselves at the end of the activity.
5 Yes 5 No
Constant supervision / The young person requires constant staff supervision.
5 Yes 5 No
Photographs / 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 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?
5 Yes 5 No
Swimming / Please indicate the young person’s swimming ability:
5 Non swimmer 5 Basic 5 Experienced
Movie rating / What rating do you approve the young person viewing in a movie or video?
5 PG 5 M 5 MA 5 MA 15+
Activity Details
Date / Activity / Price / Time / ü / Cost
1 / Wednesday 5 July / Golf Range & Ten Pin Bowling / Free / 8.45am – 3.30pm / 5
2 / Wednesday 12 July / Laserforce / $15.00 / 8.45am – 3.30pm / 5
Participants are to meet at the front of the Roxy Theatre.
The bus will depart from Roxy Theatre 8.45am SHARP for Mildura and returning to Ouyen approximately 3.30pm. / TOTAL / $

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 GuidelinesHolHoluday Hol.

·  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.