Beaconsfield Youth Centre Membership Form

Participant Details

Please indicate which dates you are attending (ages 10-12 only):
Please indicate which dates you are attending (for high school only):

IN CASE OF EMERGENCY

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

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, Sharni Rawlinson, Youth Worker of the West Tamar Council on 0429 416 310/6383 6353. 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 Beaconsfieldand surrounding areas and will only become an ongoing venture if I follow the rules and regulation

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 indicate appropriate choice]

I understand that the centre is a youth cluband the young people are only supervised whilst in the building, unless on group activities. I give permission for my son/daughter to have their photo taken whilst on the activities, to be used only by the West Tamar Council for reporting requirements/promotional material.

I authorise the leaders to contact the participant’s nominated doctorin 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.

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