Before a young person can participate in a Maroondah City Council Youth Services program, this Youth Programs Enrolment Form must be completed and submitted - before the program starts.
This form is to be completed by a parent / carer of the young person, or by the young person if they are aged 18+ years. If this is an issue, please simply contact us on 9294 5704 to discuss.
Please note that the information you provide on this form is being collected by Maroondah City Council for the strict purpose of conducting Council business. Further information can be found in the Privacy Collection Notice at the bottom of this page.
Youth Programs Enrolment Form
Has an Enrolment Form already been completed for this participant this year? * (Required)
- If any information provided on this form might have changed since it was submitted, please complete those sections of the form below where information has changed (plus any 'required' questions). Then go to the Declaration & Consent section at the end of this form, complete this section, then submit.
- If the information provided on this form has NOT changed, please go straight to the Declaration & Consent section at the end of this form, complete this section, then submit.
- Please complete the full form and submit it BEFORE the program starts.
Participant (i.e. Young Person) Details
Is the participant accessing any other relevant community agencies or support services? * (Required)
Parent / Carer Information (optional for young people aged 18 and over)
PARENT / CARER 1
PARENT / CARER 2
Emergency Contacts (must be different to parents / carers, and within close proximity if parents / carers are unavailable)
EMERGENCY CONTACT 1
EMERGENCY CONTACT 2
Custody Arrangements and Court Orders
Are there any custody arrangements and/or court orders relating to the participant that Council needs to be aware of? * (Required)
Photo / Video Consent
Do you give permission for Maroondah City Council to take and use photos and videos of the participant in any of its publications, presentations, displays, multimedia, websites, social media pages and e-communications? * (Required)
Do you give permission for the participant's first name to be used in photos / videos / etc? * (Required)
Participant's Medical Information
Does the participant have any medical conditions and/or special needs (e.g. asthma, allergies/sensitivities, anaphylaxis, dietary restrictions, mobility, speech impairments, vision or hearing impairments, mental health issues, autism, ADHD, etc)? * (Required)
Does the participant have any behavioural and/or social issues that may require additional supervision or support (e.g. aggression, shyness, difficulty making friends, literacy/numeracy issues, etc)? * (Required)
Does the participant take any medication that may impact on their behaviour, or that they carry with them?
Does the participant need additional support to participate in programs? * (Required)
Will the participant have a support worker / carer with them at the program/s?
Declaration & Consent
- In case of illness or accident, I authorise staff to seek medical or other attention as required for the named participant, at my expense.
- I agree to hold harmless Maroondah City Council, its servants and agents, and each of them from and against all claims resulting from damage, loss, death or injury whatsoever which may otherwise be brought or made or claimed by the participant or their representatives against Council.
- I agree to indemnify and to keep indemnified Maroondah City Council, its servants and agents, and each of them from and against all actions, costs, claims, charges, expenses, penalties, demands and damages whatsoever which may be brought or made or claimed against them, or any of them, arising from or in any way connected with the participant’s participation in the program.
- My liability to indemnify Maroondah City Council, its servants and agents shall be reduced proportionally to the extent that any act or omission of Maroondah City Council, its servants or agents, contributed to the loss or liability.
- I have completed this form accurately to the best of my knowledge.
- I consent to the named participant being enrolled in the above named Maroondah City Council program, and I believe they are competent to participate in this program without risk to themselves or others.
I AGREE TO ALL OF THE ABOVE: * (Required)
PRIVACY COLLECTION NOTICE
Maroondah City Council is committed to protecting your privacy as prescribed by the Privacy & Data Protection Act 2014 and the Health Records Act 2001. The information you provide on this form is being collected by Maroondah City Council for the strict purpose of conducting Council business. Your information will not be disclosed to any external party without your consent, unless Council is required or authorised to do so by law.
Failure to provide the information requested may make you ineligible to receive the service or be part of an event/function that is the subject of this form. Any access to the information, amendments that may be required or any privacy enquiries may be directed to Council's Privacy Officer & Health Records Officer on 9298 4211 or email - firstname.lastname@example.org
If you have any questions or any difficulty completing this form, please contact Youth Services on 9294 5704. Thank you!