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Youth Services membership form

Youth – Youth Services Membership Form

Young Person's Details(Required)

Given Name Surname

Gender(Required)

Does the young person identify as Aboriginal and/or Torres Strait Islander or Culturally and Linguistically diverse?(Required)

Age(Required)

Date of Birth(Required)

Young Person's Address(Required)

Street Address Address Line 2 City Postcode

Mobile Phone(Required)

Email(Required)

Parent/Guardian details…

Parent/Guardian's Name(Required)

Given Name Surname

Relation to participant(Required)

Mobile Phone(Required)

Alternate Phone(Required)

Email(Required)

Address…(Required)

Address is the same as the young person applying

Address is the not same as the young person applying

Parent/Guardian's Address(Required)

Street Address Address Line 2 Suburb State Postcode

Emergency contact…

(Please provide the details of a person over the age of 18 years other than the parent or guardian already provided on this form)

Given Name(Required)

Surname(Required)

Relation to participant(Required)

Mobile Phone(Required)

Alternate Number

Special Information

To assist us in providing appropriate care, support and a safe environment for you or your young person, please provide any relevant information you feel may impact the attendee’s participation in activities/events with the Service. Examples may include allergies, disability, mental health etc.

Consent and Behaviour Participation Agreement

I will,
ACT in a way that shows respect for the program/service, others and myself;
BELONG to a program/service that values me, my property and my personal safety;
COMMIT to being accountable for my actions.

If my actions break this agreement, staff will respond by:
1. Reminding me of the expected standards of behaviour
2. Providing me with opportunities to modify my behaviour
3. Request that I take time out from the events/activities
4. If I am still unwilling to change my behaviours, request that I leave the program/service immediately for a chosen period of time

Has the participant read and understood the consent and Behaviour Participation agreement above?(Required)

Please tick if the participant agrees with the above agreement

Parent/Guardian/Over 18’s Agreement

In the case of an accident or illness whilst participating in the Service, Program or Event, I give consent to the City to provide any necessary medical treatment and agree to meet any expenses incurred. I also give permission for the young person or myself to be transported to outside medical facilities for treatment if necessary. I acknowledge that the City is not liable for any loss, damage or injury to property or person as a consequence of my or the young person’s participation in the Service, Program or Event. I also acknowledge that I am liable for any damage to property or injury to another person caused by me or the young person.

Photos and Videos
I understand that photos and videos may be taken by City approved photographers whilst I or the young person is participating in the Service, Program or Event and that these could be used for promotional purposes. If you do not wish for the young person or yourself to be present in any photos or videos please advise the City’s Senior Youth Worker in writing.

Transport Requirements
To enable access to the City’s Youth Services, transport may be provided by or on behalf of the City for some activities and programs. This may include return trips from Youth Centres to an external location for an activity. I understand that whilst the City maintains duty of care for the young person whilst at the Service, Program or Event, including when being transported by or on behalf of the City, I acknowledge that this does not extend to those occasions when a young person is dropped off at, or collected from, or leaves independently from an external location.

Have you read and understood the Consent and Behaviour Participation Agreement listed above?*(Required)

I consent as the young person of legal age to my participation in this program subject to the conditions above

I give consent as the parent or guardian of the registered young person to participate in this program subject to the conditions above

Name of person giving consent(Required)

First Last

Date of entry(Required)

If at any time you would like to make changes to any of the above, please do so in writing by contacting the City’s Youth Services Team via youth.services@joondalup.wa.gov.au.

Comments

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