Glossop Skills Hub Enrolment Form – Term 2

☐ Powered Longboard / Mon 10am-2pm / 27th April – 29th Jun 2015 / $350 Course
$100 Materials
☐ Drag Ute / Wed 10am – 2pm / 29 April – 1st Jul 2015 / $350 course
$50 Materials
☐ Lets Go Leaner / Negotiated / 5 week program / $280
Referring Agency/School / Choose an item.
Other:
Agency/School Contact person
Email
Phone No.: / Mobile Phone No.:
Billing Details
Where is the invoice sent?
Personal Details
Participant/Student Name:
School Attending
Home Phone No.: / Mobile Phone No.:
Date of Birth: / Gender:
Details of Person to be Notified in the event of an Emergency
Name:
Home Telephone No.:
Mobile Telephone No.:
Work Telephone No.:
Relationship:
Special requirements
Personal - any information that will assist the trainer to work with the student re physical or personal limitations
Risks – court orders, restrictions or any potential risk
Medical Conditions / ☐ Allergies / ☐ Asthma / ☐ Seizures / ☐ Heart condition
☐ other:
Comments
Referral worker signature / Date

Formal agreement – Parent/Guardian

1.  In the case of an emergency , I understand that any cost incurred will be my responsibility and I give permission for ______

i.  To be taken to the nearest doctor or hospital by ambulance or car and contact made with the parent(s)/caregiver(s) as soon as possible.

ii.  To obtain medical attention. Yes / No

2. Excursions are often scheduled to support the educational programs, I agree that my child can take part in such excursions. Yes / No

3. I agree that my child can travel in FWS vehicles where appropriate. Yes / No

4. I agree that if my child, as a passenger in a car/van, is behaving in such a manner as to make conditions unsafe he/she will be removed from the program and will become the responsibility of the case manager or referring organisation. I understand that I or my emergency contact will be notified of the situation immediately. Yes / No

5. I agree that if my child is behaving in such a manner that is disruptive and/or dangerous to others, she/he will be removed from the program and will become the responsibility of the case manager. I understand that I or my emergency contact will be notified of the situation immediately. Yes / No

6. I agree that my child may watch videos deemed suitable by the teaching staff. Yes / No

7. I agree that my child may be photographed engaged in daily activities at Glossop Skills Hub and displayed at the centre and in newsletters/publications. Yes / No

8. I agree to the expectations around the appropriate use of mobile phones and other electronic devices Yes/ No

I have read the above agreements and give my consent to all information stated in this Enrolment Form.

Parent/Guardian Name
Parent/Guardian Signature / Date

Protection of Privacy & Consent to Release Information

I, agree that for FWS to provide ongoing support, services and training to me they can have access to personal information while I am engaged in a program. Specifically to:

9.  OBTAIN INFORMATION

I give permission for FWS to receive information from the following:

Agency or Worker / Initial

10.  RELEASE INFORMATION

I also give permission to FWS to release information to medical services in the situation of an emergency. Please be advised that in the event of an emergency FWS reserves the right to call an ambulance to attend.

The contents of this authorisation have been explained to me and I understand the nature of the information.

Guardian/Advocate signature
Student/participant signature
Printed Name
Date

All persons have the right to confidentiality. Information revealed will remain with the professional setting. There are however legal exceptions to this. Information must be divulged when:

·  Ordered by the court

·  Or police

If you have concerns about the way in which your personal information is being managed you should discuss these concerns with your provider, the department or agency concerned or with the Federal Privacy Commissioner, who can be contacted at www.privacy.gov.au.

Information received will be treated in accordance with the FWS Privacy Policy and procedure which can be accessed from the Website www.fws.org.au

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