Arts & Culture Program Enrolment Form 2018
ARTS & CULTURE ENROLMENT FORM
Arts & Culture Program enrolment form 2018
Term 1 Term 2 Term 3 Term 4
PARTICIPANT DETAILS STUDENT No. ______(if known)Is student under 16 years old? Yes No If yes, parent or guardian to please complete details over page.
FIRST NAME / FAMILY NAME
GENDER
______ / DATE OF BIRTH: ____/____/____ / Do you identify as experiencing disability? (optional) Yes No
Please contact us to discuss any access requirements.
ADDRESS
SUBURB / POSTCODE
PHONE / (H) / (BH) / (MOB)
Would you like to receive general Brimbank City Council Arts & Culture information (incl. courses, exhibitions) YES NO
How did you find out about this Program?
Brochure Library Customer Service Mail Out
Internet Email Radio Word of Mouth Brimbank City News
Your Brimbank The Leader Star Weekly Brimbank Learning Guide Other ….…………………………………..
Do you identify as Aboriginal and / or Torres Strait Islander origin? Yes No
What is the cultural background of your family?
Which country were you born in?
Other languages spoken at home?
What is your preferred language?
EMERGENCY CONTACT INFORMATION
Emergency Contact Person (full name) / Relationship
Emergency Contact Phone Numbers:
NAME OF PROGRAM / DAY / START DATE / COURSE FEE
SPECIAL MEDICAL NEEDS DECLARATION
Please advise us if there are any health issues STACC staff should be aware of
In the event of there being any known medical conditions or the need for the taking of medication which would affect the rendering of urgent medical assistance, details are provided below. (For example, Type 1 diabetes, allergies etc.)
______
OFFICE USE ONLY
Concession Card Verified: _
Trim No: / / / CD Yes / MLD Yes
PARENT / GUARDIAN CONSENT Parent or Guardian please complete for Children’s activities
I hereby agree and consent to ______(child’s full name) participating in the above activity. I hereby also agree to release, discharge and indemnify the Brimbank City Council and its servants and agents for any accidents, harm, loss and damages which my above named child may suffer and/or sustain, which are in any way connected to, or as a result of, the said child participating in any way in the above activity to the extent permitted by law.
I, ______(parent /guardians name) the person with lawful authority to consent to the medical treatment of the child, hereby consent to centre staff seeking necessary emergency medical, hospital, dental, or ambulance services in the event of any form of illness or accident occurring to the child, as the centre staff may determine in its absolute discretion, at my sole cost and expense.
COMMUNITY PLANNING & DEVELOPMENTVersion 1.5 8 December 2014REC.LEI.006.2
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