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Home
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Youth Empowerment Program
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YEP Events
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YEP Events Registration
Youth Empowerment Program Registration Form
Details of Person Attending
Name
(Required)
First
Last
Date of Birth
DD slash MM slash YYYY
Gender
Female
Male
Other
CCA Member Number (if applicable)
Address
Street Address
Address Line 2
City
State
Post Code
Mobile
(Required)
Email
(Required)
Details of Parent/Guardian
Name
First
Last
Relationship to Attendee
Parent/Guardian
Friend
Professional Worker
Phone
Email
Emergency Contact
Name
First
Last
Relationship to Attendee
Parent/Guardian
Friend
Professional Worker
Phone
Email
Consent
I give my permission
I (parent/guardian), give my permission for (event attendee) to attend the Crohn’s & Colitis Australia (CCA) Youth Empowerment Program (YEP!) located at Escape Hunt, Level 4, 393 George St, Sydney NSW 2000 +(02) 8355 1307
As a parent / guardian I understand that although CCA and their service providers attempt to minimise any risk of personal injury within practical boundaries, accidents do happen, and all physical activities carry the risk of personal injury. I acknowledge that there is inherent risk in the physical activities that will be undertaken as part of this program.
I understand that if leaders are concerned about the person attending in any way, they will endeavour to contact me or my alternative emergency contact on the numbers I have provided. However, in case of medical emergency, if contact cannot be established, I give permission for medical/surgical intervention, as recommended by the treating doctor. All staff hold relevant qualifications and training in first aid and CPR. All staff adhere to a child protection policy and hold current working with children checks. I understand that this policy can be made available to me at any stage.
Medical Details
Diagnosis
Crohn's Disease
Ulcerative Colitis
Other
Treating Doctor
Phone
Ambulance Cover #
Dietary Requirements
Additional Information
Code of Conduct
"that you understand what we are asking you to do and not to do, please put a tick in the circle. If you cannot or will not abide by this Code of Conduct, you won’t be able to continue taking part in the event. Attendees will be expected to: • Behave appropriately at all times • Stay with assigned groups and CCA staff or supervisors • Use appropriate language at all times • Abide by all local, state and federal laws • Respect the dignity, diversity of cultures, backgrounds and family customs of all individuals at YEP. Please note that: • Smoking, alcoholic beverages, or illegal drugs are strictly forbidden. • You are expected to treat other participants with the same respect you want for yourself. • Destruction or theft of personal, or any other property is unacceptable. • Disrespect for group facilitators, instructors and supervisors will not be tolerated. • Attendees are not allowed to leave the premises without an adult supervisor. • It is recommended that no valuable belongings be brought with you. You may bring your mobile phones, however you are responsible for your own belongings. CCA takes no responsibility for any lost property. • No destruction of property is allowed. Any damages incurred above and beyond normal wear and tear will be charged to the participant causing the damage.
I have read and agree to follow the above expectations.
“that you understand what we are asking you to do and not to do, please put a tick in the circle. If you cannot or will not abide by this Code of Conduct, you won’t be able to continue taking part in the event.
Attendees will be expected to:
• Behave appropriately at all times
• Stay with assigned groups and CCA staff or supervisors
• Use appropriate language at all times
• Abide by all local, state and federal laws
• Respect the dignity, diversity of cultures, backgrounds and family customs of all individuals at YEP.
Please note that:
• Smoking, alcoholic beverages, or illegal drugs are strictly forbidden.
• You are expected to treat other participants with the same respect you want for yourself.
• Destruction or theft of personal, or any other property is unacceptable.
• Disrespect for group facilitators, instructors and supervisors will not be tolerated.
• Attendees are not allowed to leave the premises without an adult supervisor.
• It is recommended that no valuable belongings be brought with you. You may bring your mobile phones, however you are responsible for your own belongings. CCA takes no responsibility for any lost property.
• No destruction of property is allowed. Any damages incurred above and beyond normal wear and tear will be charged to the participant causing the damage.
Travel Arrangements
The event will conclude at 5:00pm
Who will pick up the attendee
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.