July 2016 Youth School Holiday ProgramPermission 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 employeesneed to be made aware of? Yes/No If so, please attach a copy of the treatment plan to this form. If the child is 13 or under, medication needs to be signed in and out. Speak to management for more information
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 nameSignature Date
Please return to: The corner@bcs, Corner of Chandler St and Swanson Crt, Belconnen,
P: (02) 6264 0200 E:
Out of CentreExcursions
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. You will be contacted in the first week of holidays if you are allocated a place on the excursion.
Please contact me via: (please circle)
Phone call OrText message
You are required to meet staff at the corner@bcs at 12pm unless otherwise specified. Anyone who meets us at the venue without prior arrangements will not be accepted on the excursion.
Please number your preferences, 1 -5(Please only preference the excursions you actually wish to attend)
____Lazer Tag
____Movies
____Questacon
____Hip Hop Dance Class
____Skyzone
Please note: These holidays the centre will not be openon excursion days.
Office use only
Received by: ______Date received:______