KYA Permission Slip • Kyogle Together

Kyogle Youth Action Permission Slip

EVENT

Please write all upcoming events that you give permission for you child to attend.

PARTICIPANT’S DETAILS

First and last name

Age

Town/suburb

Phone

Indigenous status

Country of birth

Language at home

EMERGENCY CONTACT

Emergency contact name

Emergency contact phone

Emergency relationship

TRANSPORT OPTIONS

Transport not required Transport from Village Transport from Kyogle

Transport details:

MEDICAL INFORMATION

Does your young person have any allergies, physical or medical conditions that we should know about?

Yes No

Please add medical information here:

KYA staff are first aid trained and able to respond to first aid injuries associated with KYA activities.
KYA staff are not able to administer medication to young people. Young people must be able to self-administer their medication to participate in KYA activities. Please contact Youth Workers to discuss this further if needed.

DIETRY REQUIREMENTS

Does your young person have dietary requirements we need to know about?

Yes No

Please add dietry requirements here:

PERMISSIONS

Personal Information

I give permission for Kyogle Youth Action to record the above information and store it securely for internal reporting purposes.

Media

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 eg. 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.

Caregiver name

Caregiver relationship

Date

Behaviour

As a Parent/Caregiver I agree to have a discussion with my young person about expected behaviour when attending KYA events. They are aware that these are Alcohol, Drug and Vape free events.

Acknowledgement

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

For further information

Kyogle Youth Workers:
0406 725 166
0460 578 866

Village Youth Worker:
Kyrstie – 0458 394 713

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.

ABN 16 530 482 569 | KYA Privacy Policy