City of Whitehorse Youth Services
PROGRAM PARTICIPANT AGREEMENT
Program: Whitehorse Youth Representative Committee 2011
Personal Information – please fill in:
First Name:……………………………… Last Name:…………………………………………………
Preferred Name:………………………………………………….……………………………………………
Email Address:………………………………………………………………………………………………….
Address:…………………………………………………………….. Postcode………......
Phone number(s):…………………………………………………………………………………………….
Date of Birth:……………………………….. Country of Birth:………………………………………….
Preferred language:…………….….. School Attending:…………………...……………………..
Gender: Male / Female
Emergency Contact: Name:……………………………….. Phone Number………………………
Relationship to participant: ………………………………………………………………………
Medical Information – please circle
Do you suffer from any illness or medical conditions? Yes / No
Are you allergic to any drugs or medication? Yes / No
Are you allergic to bandaids/ antiseptic creams/ anti bacterial lotions? Yes / No
Do you suffer from any allergic reactions to bees / wasps?Yes / No
Do you suffer from any allergic reactions to anything else?Yes / No
Are there any foods you don’t eat due to religious or health reasons?Yes / No
If you answered ‘yes’ to any of the above, please detail below
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Photographs
Do you give permission for Whitehorse City Council to take and use you / your child’s photograph for promotional purposes if required? Please Circle:Yes / No
PLEASE TURN PAGE OVER AND SIGN
Confidentiality – please read:
For parents / guardian: Anything discussed by your child during the program will be treated as confidential, unless your child is at risk of harming themselves or others, or at risk of harm from others. Workers will not disclose any other information to any person including parents / guardians without the express permission of your child. Your child will be encouraged to utilize family support if appropriate.
For young people: Anything you discuss with program staff will be treated confidentially, unless staff are concerned that you are at risk of harming yourself or others, or at risk of harm from others. In this case, staff will work with you to ensure the best outcome.
Indemnity Statement – please read and sign:
By signing below, I agree to attend and participate in youth programs. I understand that any hurt, loss injury or damage sustained by me or to my property during the course is not the responsibility of the Whitehorse City Council, its staff and volunteers. In the event of accident or illness, I give course staff permission to obtain the necessary medical assistance to protect my welfare.
Signed…………………………………………………………Date…………………
(If you are under 18, this form must be signed by a parent or guardian)
Parents/Guardians Signature………………………………..Date…………………
Relationship to Participant……………………………………………………………….
Please callYouth ConneXions on 9898 9340 if you have any questions about this form or if you would like this form in another language.
Whitehorse City Council Privacy Policy
Personal information provided for this form will be used exclusively for the purposes stated and will not be passed on to other parties, with the exception of mandated health and welfare services for medical or legal reasons. This information will be maintained in a secure facility for a period of 7 years, when it will be destroyed.