KYA Permission Slip • Kyogle Together

Kyogle Youth Action Permission Slip

Event

Date

PARTICIPANT’S DETAILS

Name

Date of birth

Address

Phone

Indigenous status

Country of birth

Language at home

I want to receive KYA Newsletters and updates

EMERGENCY CONTACT

Emergency contact name

Emergency contact phone

Emergency relationship

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.

COVID-19 POLICY

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 youth.worker@kyogletogether.org.au

Caregiver name

Caregiver relationship

Date

I acknowledge that entering my details here is the equivalent of signing