Youth Services Membership Form

Young Person's Details * Required
Given Name Surname
Gender * Required
Does the young person identify as Aboriginal and/or Torres Strait Islander or Culturally and Linguistically diverse? * Required
Age * Required
Date of Birth - must be dd/mm/yyyy format * Required
DD slash MM slash YYYY
Young Person's Address * Required
Street Address Address Line 2 City Postcode
Mobile Phone * Required
Email * Required
Parent/Guardian details...
Parent/Guardian's Name * Required
Given Name Surname
Relation to participant * Required
Mobile Phone * Required
Alternate Phone * Required
Email * Required
Address... * Required
- Address is the same as the young person applying
- Address is the not same as the young person applying
Parent/Guardian's Address * Required
Street Address Address Line 2 Suburb State Postcode
Emergency contact...
(Please provide the details of a person over the age of 18 years other than the parent or guardian already provided on this form)
Given Name * Required
Surname * Required
Relation to participant * Required
Mobile Phone * Required
Alternate Number
Special Information
To assist us in providing appropriate care, support and a safe environment for you or your young person, please provide any relevant information you feel may impact the attendee’s participation in activities/events with the Service. Examples may include allergies, disability, mental health etc.
Consent and Behaviour Participation Agreement
I will,
ACT in a way that shows respect for the program/service, others and myself;
BELONG to a program/service that values me, my property and my personal safety;
COMMIT to being accountable for my actions.

If my actions break this agreement, staff will respond by:
1. Reminding me of the expected standards of behaviour
2. Providing me with opportunities to modify my behaviour
3. Request that I take time out from the events/activities
4. If I am still unwilling to change my behaviours, request that I leave the program/service immediately for a chosen period of time
Has the participant read and understood the consent and Behaviour Participation agreement above? * Required
- Please tick if the participant agrees with the above agreement
Parent/Guardian/Over 18’s Agreement
In the case of an accident or illness whilst participating in the Service, Program or Event, I give consent to the City to provide any necessary medical treatment and agree to meet any expenses incurred. I also give permission for the young person or myself to be transported to outside medical facilities for treatment if necessary. I acknowledge that the City is not liable for any loss, damage or injury to property or person as a consequence of my or the young person’s participation in the Service, Program or Event. I also acknowledge that I am liable for any damage to property or injury to another person caused by me or the young person.

Photos and Videos
I understand that photos and videos may be taken by City approved photographers whilst I or the young person is participating in the Service, Program or Event and that these could be used for promotional purposes. If you do not wish for the young person or yourself to be present in any photos or videos please advise the City’s Senior Youth Worker in writing.

Transport Requirements
To enable access to the City’s Youth Services, transport may be provided by or on behalf of the City for some activities and programs. This may include return trips from Youth Centres to an external location for an activity. I understand that whilst the City maintains duty of care for the young person whilst at the Service, Program or Event, including when being transported by or on behalf of the City, I acknowledge that this does not extend to those occasions when a young person is dropped off at, or collected from, or leaves independently from an external location.
Have you read and understood the Consent and Behaviour Participation Agreement listed above?* * Required
- I consent as the young person of legal age to my participation in this program subject to the conditions above
- I give consent as the parent or guardian of the registered young person to participate in this program subject to the conditions above
Name of person giving consent * Required
First Last
Date of entry - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
If at any time you would like to make changes to any of the above, please do so in writing by contacting the City’s Youth Services Team via youth.services@joondalup.wa.gov.au.

Parent/Guardian details...

Emergency contact...

Consent and Behaviour Participation Agreement

Parent/Guardian/Over 18’s Agreement

Related Topics

Youth Services