Hills Community Aid Registration Form

Hills Community Aid Registration Form
PERSONAL INFORMATION
Name*

First NameLast Name
Program/Workshop
Address*
Suburb*
Postcode*
Home Phone
Format: (00) 0000 0000.
Mobile
Format: 0000 000 000.
Email*
example@example.com
Date of Birth*

DayMonthYear
Date
Country of Birth*
Main Language Spoken at Home*
Gender
Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
Sensory/SpeechIntellectual/LearningPsychiatricPhysicalOther
YesNo
Child's Name 2*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender
Child's Country of Birth*
Main Language Spoken at Home*
Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
Sensory/SpeechIntellectual/LearningPsychiatricPhysicalOther
YesNo
Child's Name 3*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender
Child's Country of Birth*
Main Language Spoken at Home*
Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
Sensory/SpeechIntellectual/LearningPsychiatricPhysicalOther
YesNo
Child's Name 4*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender
Child's Country of Birth*
Main Language Spoken at Home*
Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
Sensory/SpeechIntellectual/LearningPsychiatricPhysicalOther
YesNo
Child's Name 5*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender
Child's Country of Birth*
Main Language Spoken at Home*
Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
Sensory/SpeechIntellectual/LearningPsychiatricPhysicalOther
YesNo
Child's Name 6*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender
Child's Country of Birth*
Main Language Spoken at Home*
Yes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderNo
Sensory/SpeechIntellectual/LearningPsychiatricPhysicalOther
Emergency Contact Details
Emergency Contact Name*

First NameLast Name
Relationship to you*
Emergency Contact Phone*
Format: 0000 000 000.
Consent
YesYes, unidentified or identity suppressedNo
The information you provide on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. We are using an IT system called the 'Data Exchange' to store your information. This system is hosted by the Australian Government Department of Social Services (DSS The personal information that is stored on the Data Exchange is only disclosed to us for the purpose of managing your case. You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do consent to sharing your personal information with DSS, you can ask for this information to be removed at any time. DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g. your name DSS combine your data with other clients' data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grants programs, and conduct research and evaluations. DSS may use this data to produce reports. These reports may be shared with other organisations. The data in these reports is de-identified. You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website.
YesNo
YesNo
Covid-19 Vaccination Status

In line with NSW Health directives, Hills Community Aid requires all participants attending face to face workshops and classes to show proof of vaccination when enrolling. Please upload a copy of your records below.
File Upload

Cancelof
Terms & Conditions
1. Children under the age of 16 are required to have parental authority to participate in any workshop.

2. I acknowledge that it is my responsibility to undertake the workshops within my own limits and capabilities and will not participate in a workshop if feeling unwell or under medical restrictions.

3. I expressly waive any claims I may have against Hills Community Aid for any injury or loss sustained by me while undertaking any class.

4. Hills Community Aid (HCA)/Learning in the Hills reserves the right to cancel any workshop due to insufficient student enrolments, Government or Council directives or Tutor illness. Credit will be available where HCA has cancelled the class.

5. I understand I am required to adhere to Government Covid Safe practices as required while participating in the workshops. This includes providing a record of my vaccination status for face to face classes and workshops.
YesNo
Signature: (parent signature if under 16)*

Clear
WebsiteSocial MediaA friend or family memberPrinted flierVia a referralOther
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact Details

Consent

Covid-19 Vaccination Status

Terms & Conditions