Youth Services Enrolment Form | Golden Plains Shire Council

Current Young Person Details
Parent/Guardian/Carer's Details
Behaviour Management Agreement
Photograph/Video Consent
Consent, Acknowledgements and Arrangements
Complete

Young Person Details

Title:

Given Name:

Family Name:

Preferred Name:

Address:

Email:

Golden Plains Shire Youth programs are open to ages 12 to 25 years.
Some programs will have more specific age requirements within this age bracket.

Age:

Date of Birth:

Phone:

Gender:

Male

Female

Non-Binary

Transgender/Gender Diverse

Prefer not to say

Pronouns:

Accessibility and Inclusivity

Do you have any access or support requirements to participate fully in Youth Services programs?

Yes

What reasonable adjustments would support you to participate? Please provide any support plans.

Youth staff may contact you in relation to the above.

Cultural Diversity

Is the participant of Aboriginal or Torres Strait Islander descent?

Yes

Prefer not to say

Does the participant have any cultural requirements?

Yes

Please specify:

Participant's Medical Information

Please Note: Youth Services Staff ARE NOT authorised to administer medications of any kind, unless in the process of administering first aid. In the event of a medical emergency an ambulance or appropriate medical services will be called.

Does the participant have any medical conditions, allergies or take any medication? (Please include food allergies here)

Yes

Please provide details:

Please attach any relating medical plans (Asthma Action/Anaphylaxis Action Plans):

Maximum 4 files.
64 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.