HOLIDAY ACTION ENROLMENT FORM - Rural City of Mildura



SCHOOL HOLIDAY ENROLMENT FORM

Youth Services Mildura | ( (03) 5018 8280 | youthservices@mildura..au

|Young Person’s Details |

|First name: | |Last name: | |Preferred name: | |

|Address: | |Suburb: | |

|Postcode: | |Email: | |

|Age: | |

|Parent or Guardian Details |

|Relationship to young person: |( Parent ( Grandparent ( Guardian / Carer ( Worker |

|Other: | |

|First name: | |Last name: | |

|( (mobile): | |( (home): | |

|Is your address the same as the young person’s? |( Yes ( No (if no, complete the following) |

|Address: | |

|Suburb: | |Postcode: | |

|Emergency Contact |

|First name: | |Last name: | |

|Relationship: | |( (mobile): | |

|Picking up the Young Person (who is authorised to collect the young person, other than the parent or guardian?) |

|Full name: | |Full name: | |

|Relationship: | |Relationship: | |

|( (mobile): | |( (mobile): | |

|Family Arrangements |

|Are there any custody arrangements? |( Yes ( No (if yes, please photocopy and attach to this form) |

|Health and Wellbeing |

| |

|To create an opportunity for the young person to have an enjoyable experience in the program, could you please indicate if any of the following apply? |

|( Disability ( Asthma | |( Allergies |( Epilepsy |( Medication |

|( Additional or complex needs |( Other medical condition |( Behavioural issues |

|( Dietary requirements |(If yes, please provide |________________________________________________ |

| |details) | |

|Supervision |

|Leaving the program |The young person is allowed to leave the Scout Hall by themselves at the end of the activity. |

| |( Yes ( No |

|Constant supervision |The young person requires constant staff supervision. |

| |( Yes ( No |

|Photographs |Do you allow for photographs / video footage to be taken of your young person during programs and also acknowledge that any |

| |photographs taken will be stored in Council’s photographic library and will be used and disclosed to all Council staff, |

| |contractors and suppliers involved in the designing, publishing and printing of Council publications and other editorial |

| |material for distribution to the general public? Do you further acknowledge that you will immediately advise Council should|

| |your circumstances change or should you wish to revoke your consent? |

| |( Yes ( No |

|Swimming |Please indicate the young person’s swimming ability: |

| |( Non swimmer ( Basic ( Experienced |

|Movie rating |What rating do you approve the young person viewing in a movie or video? |

| |( PG ( M ( MA ( MA 15+ |

|Activity Details |

|Week |Date |Activity |

I, ___________________________________________ (Insert Parent/ Guardian Name in BLOCK CAPITALS if written)

• Agree to the participation of the abovementioned young person in Mildura Rural City Council School Program activities.

• Agree that I have read and understand the School Holiday GuidelinesHolHoluday Hol.

• Confirm the above information I have provided on this form is true and correct.

|MILDURA RURAL CITY COUNCIL PRIVACY COLLECTION STATEMENT |

|Mildura Rural City Council collects Personal and or Health Information for municipal purposes as specified in the Privacy and Data Protection Act 2014.  |

|The information collected in this form is used only for the purposes specified (primary purpose) and is not passed on to third parties.  Council may |

|disclose this information but only if authorised or required by law.  Council may not be able to process your request unless sufficient information is |

|given.  Should you need to change or access your personal details, or you require further information regarding Council’s Privacy Policy please contact |

|Council’s Privacy Officer. |

      ___________ (Parent/ Guardian Signature)       (Date)

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