Beaconsfield Youth Centre Membership Form

Participant Details

Participant's Name

Parent's Name

Address

Contact Number

Email Address

Date of Birth

School & Year Level

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

Sep 16 Oct 21 Oct 28 Nov 4 Nov 11 Nov 18 Nov 25 Dec 2 Dec 9

Please indicate which dates you are attending (for high school only):

14th Sep 19th Oct 26th Oct 9th Nov 16th Nov 23rd Nov 30th Nov 7th Dec

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 numbers that we can contact)

1st Emergency Contact

2nd Emergency 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

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 indicate appropriate choice]

Travel

Collect my child/children each night(prior to closingotherwise suspension may apply)

Allow them to walk home

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.

Parental Agreement

I agree to the above

Parent/Guardian’s Name

Parent/Guardian's Phone Number

Date