Participant Form

Participant Form

School Holiday Workshops
Please read and complete the following details before your child participates in a workshop at Moonah Arts Centre.
Name of Workshop*
Date of workshop*

MonthDayYear
Date
Participant's Details
Participant's Name*

First NameLast Name
Participant's Pronouns*
Parent's/Guardian's Details
Parent's/Guardian's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Back up Phone Number if available (ie. work/home)
Please enter a valid phone number.
Drop off & Collection
Same as Parent/Guardian above?

YesNo
Who will be collecting the Participant*
Contact number for the person collecting the Participant*
In case of an emergency please contact
Same as Parent/Guardian listed above?

YesNo
Full Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Medical Information
Does the participant have any allergies?*

YesNo
Details of allergies
Please specify triggers, etc.
Does the participant have any additional or specific needs that we should be aware of?
Anything else we should know? Other notes and comments?
Image consent
By signing this form I, the undersigned, consent to Moonah Arts Centre and Glenorchy City Council (Council) using and publishing my/my child’s first name and any photographs and/or videos (including audio) taken during the workshop on its website and in any publications and materials, including written, electronic or multimedia materials, for distribution anywhere in the world, for promotional, educational or reporting purposes.

In giving consent, I acknowledge and agree that:
- The photographs/videos may contain my/my child’s image.
- The photographs/videos may contain my/my child’s artwork.
- I am not entitled to any remuneration, royalties or any other payment from Council in respect of the use by Council of the photographs and/or videos.
- the artwork created during the workshop remains the intellectual property of the Participant who created it.
- Any photographs/videos taken during the workshop remain the intellectual property of Council.
- Any information published on the internet is accessible to millions of users from all over the world, will be indexed by search engines and may be copied and used by any web user, and that Council will have no control over its subsequent use and disclosure.
Does the Participant consent to the above?*

YesNo
Does the Parent/Guardian consent to the above? (if Participant is under 18)*

YesNo
Parent/Guardian Full Name (if Participant is under 18)

First NameLast Name
Parent/Guardian Signature (if Participant is under 18)

Clear
PERSONAL INFORMATION PROTECTION STATEMENT

Personal information is collected from you for the purpose of obtaining consent to publish photographs, or audio-video footage as detailed above. Personal information is managed in accordance with the Personal Information Protection Act 2004 including that such information will not be disclosed to any other party, except with your permission or if required or authorised by law. You may access or amend your personal information by application to Council.
Should be Empty:

Participant's Details

Parent's/Guardian's Details

Drop off & Collection

In case of an emergency please contact

Medical Information

Image consent