School holiday Street Art project

Young artists - This one is for you!

Professional artists Chuck Mayfield and Bryan Itch are coming to Croydon to mentor young artists and collaboratively create a unique street art piece!

Artists of all experience levels are encouraged to come along, this will be an opportunity to practice your skills and learn some new ones!

Project details:

Initial workshop to meet Chuck and Bryan and your fellow young artists

Wednesday 14 April 1-5pm

EV's Youth Centre - 212 Mt Dandenong Rd, Croydon

On site painting days

12-5pm on Thursday 15th, Friday 16th, Saturday 17th & Sunday 18th April

Pierson Street, Croydon

To be part of the project you need to;

- be between 15-25 years old

- be able to get yourself to EV's Youth Centre and Pierson Street, Croydon on the relevant dates as listed above

Once you have completed the form, you will receive a confirmation text and email from one of our youth workers.

We look forward to working with you on this project!

Youth Programs Enrolment Form Name of person completing this form * (Required) Relationship to the participant (i.e. young person) enrolling in a program - if this form is being completed by the participant, please write 'self' * (Required) Please select which Youth Services Program the participant in enrolling in: * (Required) How did you hear about us? Has an Enrolment Form already been completed for this participant this year? * (Required) Yes
No If YES: - 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. If NO: - Please complete the full form and submit it BEFORE the program starts. Participant (i.e. Young Person) Details First name * (Required) Last name * (Required) Date of birth * (Required) Gender Pronouns Street address * (Required) Suburb * (Required) Postcode Email address Home phone number Mobile phone number * (Required) School currently attending & year level (if applicable) Language(s) spoken at home * (Required) Does the participant need any language support? If yes, please provide details. * (Required) Is the participant accessing any other relevant community agencies or support services? * (Required) Yes
No If yes, to help us to support the participant please provide any relevant details (e.g. agency name, type of service, etc) Parent / Carer Information (optional for young people aged 18 and over) PARENT / CARER 1 Name: Address: Home phone number Mobile phone number Language spoken at home PARENT / CARER 2 Name Address Home phone number Mobile phone number Language spoken at home Emergency Contacts (must be different to parents / carers, and within close proximity if parents / carers are unavailable) EMERGENCY CONTACT 1 Name * (Required) Address Home phone number Mobile phone number * (Required) Relationship to participant * (Required) EMERGENCY CONTACT 2 Name * (Required) Address Home phone number Mobile phone number * (Required) Relationship to participant * (Required) 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) Yes
No If yes, please provide details 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) Yes
No Do you give permission for the participant's first name to be used in photos / videos / etc? * (Required) Yes
No Transport Consent Do you give permission for the participant to be transported in a Council vehicle for activities related to the program they are enrolling in? (not relevant for Peaceful Kids & Peaceful Parents) * (Required) Yes
No 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) Yes
No If yes, please provide details of the medical condition or special need, and of any management procedures to be followed Please list any allergies or dietary requirements If a health care provider has created a management plan, action plan or safety plan for the participant, please attach a copy here 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) Yes
No If yes, please provide as much information as possible to best assist staff to support the participant and others involved in the program Does the participant take any medication that may impact on their behaviour, or that they carry with them? Yes
No If yes, please provide details of the medication, its effects, and any management procedures in respect to the medication Does the participant need additional support to participate in programs? * (Required) Yes
No If yes, please specify the additional support requirements Will the participant have a support worker / carer with them at the program/s? Yes
No
Not sure Which agency (if any) currently supports the participant's additional needs? Other Information Is there anything else that Council should know about the participant? 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) Yes, I agree Your name * (Required) Your relationship to the participant (i.e. young person) - if signed by the participant, write self * (Required) Date * (Required)Date * (Required)

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If this form has been completed for a participant aged under 18, please provide a mobile number or home phone number for the parent / carer to confirm their consent 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 - privacy@maroondah.vic.gov.au If you have any questions or any difficulty completing this form, please contact Youth Services on 9294 5704. Thank you! Submit