Personal Details of Participant

Name: _____________________________________

Date of birth: ________________________________

Age: _______________________________________

Address: ___________________________________

___________________________________________

Email: _____________________________________

Parent/Guardian Contact Details (if under 18 years)

Name of parent/guardian: _____________________

Relationship to participant: _____________________

Address: ___________________________________

Telephone: (Home): ___________________________

(Work): ____________________________________

(Mobile): ___________________________________

Email: _____________________________________

Emergency Contact

Name of contact: _____________________________

Telephone: (Home): ___________________________

(Mobile): ___________________________________

Medical Information or Special Needs Considerations

Please describe any medical conditions, special needs or

medications that affect your child’s health or any other

special requirements your child may have.

Please specify: _______________________________

___________________________________________

___________________________________________

Youth Development Connecting Mandurah’s Youth

www.mandurah.wa.gov.au/avclub

@mandurahyouth

Learn new skills to create your own multimedia projects

AV Club

Held at FabLab @ Falcon eLibrary Corner of Flavia St and Cobblers Ave,

Falcon WA 6210

E: youthdevelopment@mandurah.wa.gov.au

P: 9550 3674

Video | Sound | Photography

Internet Friends Agencies BDYC Other

How did you hear about this program?

Application Form

Application FormParticipant’s Agreement

I am aware that the City of Mandurah’s Youth Development advocates a safe place for all young people. To keep it safe I undertake not to annoy, harass, tease or bully others. I will respect the City of Mandurah’s buildings and property, and any vehicles that I may travel in. My behaviour includes not being under the influence of alcohol and drugs. If my behaviour breaks this agreement I understand that I will be asked to leave the centre or activity immediately. I acknowledge that my parents will be informed of my behaviour. My parents will be expected to meet any costs relating to any damage I have caused and my removal from the program. I expect that other young people and staff will treat me with respect.

Young person sign: _________________Date: ____________________________

Parent/Guardian Consent (if under 18 years)

I understand that it is my responsibility to familiarise myself with the activities participated in by my child, and will make appropriate arrangements for my child to be dropped off and picked up from the venue. I give permission for my child to be transported by public transport, private charter bus and/or private car while on the program. In the event of any accident or illness suffered by my child I authorise the organisers of this program to obtain on my behalf, any medical assistance that my child may require and I agree to reimburse the organisers for any expenses incurred by doing so. I understand that City of Mandurah Youth Development have a behaviour policy and that if my child breaches that policy they could be immediately excluded from the program at the supervisor’s discretion. Furthermore, should my child damage anything and be required to leave, I will either collect my child from the venue or alternately will cover any transport cost for the conveyance of my child to their home or any other appropriate place. My child has read and understands the young person’s agreement and has signed their name above.

Parent/guardian sign: _______________ Date: ____________________________

Photo Release (Optional)

I give my permission for photographs and video footage of my child’s participation in endorsed City of Mandurah activities, programs and events and in AV Club participant’s projects to be used for promotional, educational and report purposes by the City of Mandurah without any reward for the publication of photographs and videos.

Parent/guardian sign: _______________Date: ____________________________

Where is it?FabLab @ Falcon eLibrary on Thursdays, 5.30 -7.30pm When does it start?21 July 2016 How much does it cost?Free How do I join?Bring a completed application form or fill one out at your first AV Club session. What age can join the AV Club?Recommended for ages 15 - 25

AV Club