Kyogle Youth Action Permission Slip
Date of birth
Torres Strait Islander
Aboriginal and Torres Strait Islander
Country of birth
Language at home
I want to receive KYA Newsletters and updates
Emergency contact name
Emergency contact phone
I give permission for Kyogle Youth Action to record the above information and store it securely for internal reporting purposes.
I give permission for audio or visual recordings of my child to be taken on the day if they wish and used for promotion and internal reporting. E.g. interviews and/or photographs.
By filling and signing this form you give permission for your young person to attend this event and engage in the activities held.
If applicable you are also giving your young person permission to travel to and from the event using a bus service organised by KYA. It is your responsibility to organise pick up / drop off at the agreed meeting point at the times given by KYA.
The participant has not been in a COVID-19 hotspot in the last 14 days
The participant does not have any COVID-19 Symptoms
The participant has not been in contact with anyone who has had COVID-19 within the last 14 days
If you are not able to confirm all this criteria please provide information about your situation in relation to COVID-19:
By signing this form you also agree for us to hold onto your information and share it with NSW Health if in the unlikely event there is an incident of COVID-19 and contact tracing is required. Thanks for your co-operation.
If you have any concerns about this process please feel free to contact us on (02) 5601 5997.
You can also email us at firstname.lastname@example.org
I acknowledge that entering my details here is the equivalent of signing
Kyogle Together Inc. acknowledges the Gullibul, Githabul, Wahlubal and Banjalang people who are the Traditional Custodians of the land and waters within the Kyogle Local Government Area, and we pay our respects to Elders past, present and emerging.