Pannawonica January School Holiday Program 2015

Pannawonica January School Holiday Program 2015

• A fee of $5 per child applies to each activity and must be paid at the time of form submission.
• Children 6yrs & under must be supervised by a parent/guardian for the duration of the workshop, 8yrs & under applies to the scavenger hunt.
• Bookings will not be taken on the day of the activity.

For enquiries contact 9184 1038, or email

Workshop / Date and Location / Time and Cost / Tick / Parent Signature
Scavenger Hunt
(5+yrs) / Mon 12 Jan
Library / 4 to 5pm
$5
Pizza Making and Movies
(5 to 8yrs) / Wed 14 Jan
Youth Club/Cinema Room / 12 to 2.30pm
$5
Pizza Making and Movies
(9+years) / Wed 14 Jan
Youth Club/Cinema Room / 4 to 6.30pm
$5
Healthy Eating & Skateboard DeckDesign (5 to 8yrs) / Fri 16 Jan
Skate Park / 3 to 4.30pm
$5
Healthy Eating & Skateboard DeckDesign (9+yrs) / Fri 16 Jan
Skate Park / 5 to 6.30pm
$5
Aussie Activities
(5 to 8yrs) / Mon 19 Jan
Community Hall / 9 to 10.30am
$5
Aussie Activities
(9+yrs) / Mon 19 Jan
Community Hall / 11 to 12.30pm
$5
Aussie Cooking
(5 to 8yrs) / Wed 21 Jan
Youth Club / 9 to 11am
$5
Aussie Cooking
(9+yrs) / Wed 21 Jan
Youth Club / 12 to 2pm
$5
Family Picnic &
Water Bottle Raft Building / Fri 23 Jan
The Rocks / 4 to 6pm
$5

Participant details

First Name / Last Name
Male / Female / Date of Birth / / /
Street / Suburb / Town
Parent /Guardian 1 / Parent /Guardian 2
Name / Name
Home / Home
Work / Work
Mobile / Mobile

Emergency contacts

Please provide details of people we can contact in the event of an emergency. Do not include the people above.It is important to note that emergency contacts should be contactable during the hours your child will be in the school holiday program.

Name / Name
Relationship to Child / Relationship to Child
Phone / Phone

Medical Information or special needs considerations

Please describe any medical conditions that affect your child’s health or any other special requirements your child may have (allergies, asthma, ADD, vegetarian or wheelchair access etc)

Media consent

I/we give consent for my/our child to be photographed by a Shire of Ashburton officer or representative from the media.

By signing this section, I understand that my child may be photographed and these photographs may be used by The Shire of Ashburton and Rio Tinto in a range of media, including hard copy and electronic formats such as newspapers, magazine, photo exhibitions, publications, power point presentations and websites.

Parent/Guardian name (print)
Signed / Date / / /

Parent/Guardian’s Consent/Release

1. I/we give consent for my/our child to take part in the program, excursions and activities. I have read and fully understand all the additional information I have received regarding the program.

2. I/we agree that neither the Shire of Ashburton nor its officers or servants are liable for any damage or injury that may be incurred by my/our young person attending youth programs or any of the activities in connection with the programs, including excursions or camps.

3. I/we authorise the staff in the event of any illness or accident to obtain on my/our behalf any such medical assistance as my/our young person may requireIn case of emergency I/we agree for my/our young person to be transported by Ambulance or private motor vehicle.

4. In the event of my/our young person behaving irresponsibly and/or not complying with safety rules, I/we agree to immediately collect my/our young person from the program or to reimburse Council for any costs involved in the return of my/our young person from the program.

5. I/we also agree to supply my/our young person with all necessary medication (e.g. asthma puffer). I understand that my/our child will not be allowed to attend the activity unless all medication has been supplied and that my/our child is able to self-administer and required medication. Shire of Ashburton staff can store medication for the duration of the activity where necessary.

6. I/we understand that staff cannot administer medication to my/our young person.

7. I/we understand and accept that it is my/our responsibility to advise Shire staff of any changes to the information supplied (including medical).

Parent/Guardian name (print)
Signed / Date / / /