Beaconsfield Youth Centre Membership Form

Registrations are now open!

2025 Participant Details

Participant's Name

PERSONAL DETAILS

Participant's Date of Birth

Residential Address

Contact number

Email Address

School & Grade Level

Medical Information - Medical Conditions, Allergies, Dietary Requirements (please specify)

Please detail medications and name of family doctor

IN CASE OF EMERGENCY

(please provide 2 names and 2 phone numbers that we can contact)

1st Emergency Contact (name & phone)

2nd Emergency Contact (name & phone)

Please Note: All the information provided is treated in the strictest confidence, including any health information given. This information is sought in order to protect & assist the participant so that the activity may be a safe & enjoyable experience. If you have any questions please contact the coordinator of the Youth Centre, Kirsten Howard on 0437 789 103 or 6323 9206. If this form is not signed by a parent or guardian, access to the Youth Club and its activities will be refused.

PARTICIPANT’S BEHAVIOURAL CONTRACT

I agree to abide by the rules and values of The Beaconsfield Youth Centre, which have been set down. I also agree to respect the other users of the centre, the staff, volunteers and the neighbours in the area. If I break these rules, I can expect the appropriate warning or suspension from the Centre. I understand that the centre has been opened for the youth of Beaconsfield & surrounding areas, and will only become an ongoing venture if I follow the rules and regulations.

Participant Agreement

I agree with the above

Participant's Name

Date

PARENT/GUARDIAN CONSENT

I hereby give consent for my child to participate in activities at the youth club. I understand that transport to and from the centre is not the responsibility of the leaders or the program and will [Please select ALL options below that apply]

I allow my child to walk home I will collect my child (suspensions will apply if late several times) I allow my child to travel home with another family

I understand that the centre is a youth club and the young people are only supervised whilst in the building, unless on group outdoor activities.

I authorise the leaders to contact the participant’s nominated doctor in the event of an emergency, obtain other medical assistance deemed necessary in the event of an emergency/accident, including the administration of an anaesthetic or the carrying out of necessary surgical procedures by a qualified medical practitioner. I agree to pay all medical and dental expenses incurred onbehalf of the above participant. The health information supplied above is accurate to the best of my knowledge.

I agree to save Kirsten's phone number in my phone (0437 789 103).

Parental Agreement

I agree to the above

Parent/Guardian’s Name

Parent/Guardian's Phone Number

Date

PHOTOGRAPHIC CONSENT

I consent for my childs photograph to be taken and used for the purpose of West Tamar Council marketing and advertising of youth programs. These images will only used on Council registered websites and social media pages such as YAC West Tamar on Facebook, yacwesttamar on Instagram and westtamaryouth.com.au, as well as all West Tamar Council pages and sites. I understand if i select NO that my child will not be photographed at any Council programs or events.