Jarrahdale Youth Registration Form

Jarrahdale Youth Registration Form
The Jarrahdale Youth (JY) program targets youth in school years six, seven, and eight who are living in Jarrahdale and surrounding rural areas.

Our mission is to understand youth's needs, actively engage young people to ensure they feel empowered and enhance positive community attitudes towards adolescents.

Please fill out this form if you are a parent/guardian of youth in SCHOOL YEARS 6-8. (One form per participant).
Parent/Guardian Information

Also emergency contact
Name of parent or guardian

First NameLast Name
Parent/guardian phone number

Area CodePhone Number
Parent/guardian email
example@example.com
Participant Information
Youth participant Name

First NameLast Name
Youth participant date of birth
MM/DD/YYYY
School year participant is currently enrolled
Youth participant address (will only be used incase of emergency)

Street Address

Street Address Line 2

CityState

Postal Code
Are there any medical conditions or medications we should be aware of?
Terms & Conditions
As the parent/guardian, I hereby give my consent for the youth participation in the Jarrahdale Community Collective's Jarrahdale Youth program. I am aware of the risks and hazards inherent in this activity, and assume all of the risks normally incidental to the nature of this activity and assume all risks of damage, or injury, including death that may be sustained while participating in this activity.

I agree
In the event of an emergency do you consent for Youth Leaders to call an ambulance

YesNo
Do you have ambulance cover?

YesNo
Jarrahdale Youth program is a drop in drop out program. Drop in/out activities allow participants to choose when they want to arrive or leave and can do so at any time during the activity (4pm-6pm). Volunteers and youth workers supervising the activity are not be responsible for the where-a-bouts of youth who leave the facility. We recommend parents discuss a plan with children and if necessary to stay for the duration of the program.

I understand and have set up a safe home procedure or will be picking up participant
As the participant or parent/guardian of participant I herby grant Jarrahdale Community Collective volunteers, associates and designated representatives permission to take photos/videos of myself/child and use my likeness in any and all publications, including website, social media and print without payment or any other consideration.

YesNo
Printed name of participant or parent/guardian
Signature of participant or parent/guardian
Should be Empty:

Jarrahdale Youth Registration Form

Parent/Guardian Information

Participant Information

Terms & Conditions