La Perouse Youth Haven

Enrollment Form

Please complete all sections

First Name *

Last Name *

Date of Birth *

Gender *

MaleFemaleOther

Email Address

Phone Number

Address *

Suburb *

State *

Postcode *

School *

Year *

Does the participant identify as Aboriginal and Torres Strait Islander *

Yes, Aboriginal Yes, Torres Strait IslanderYes, Aboriginal and Torres Strait Islander No

Please provide details of the people you wish us to contact in case of an emergency

Person 1: *

Email Address 1: *

Phone 1: *

Person 2:

Email Address 2:

Phone 2:

Please note that all information is confidential

Does the participant have any medical conditions or medication details that our staff need to be aware of?

Does the participant have any allergies/intolerances that our staff need to be aware of?

Any prescribed medications or treatment required:

Persmission to be photographed, filmed, use transport service and activites by the La Perouse Youth Haven

I give permission for my child to attend and participate in activities by the La Perouse Youth Haven *

YesNo

I give permission for my child to be photographed and filmed during these activities and events *

YesNo

I give permission for my child to use the transport service provided by the La Perouse Youth Haven *

YesNo

Parent/Careers name: *

Parent/careers signature: *

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