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Cockburn Youth Centre Membership Form
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Youth and Young Adults (10-24 years)
Youth Centre
Cockburn Youth Centre Membership Form
Print Blank Form
Cockburn Youth Centre Membership Form
All fields are required except where indicated
Cockburn Youth Centre memberships are for young people aged 10 – 24 yrs.
Membership is free and it enables you to book into our great programs each school term and school holidays. You can also receive emails with our programs and current news about things to do in cockburn.
Participant details
Pronouns (select from the drop box below - optional):
Please select
She/her
He/him
They/them
Other
Young person's name:
Young person's surname:
Date of birth:
Calendar
Gender:
Address:
Note: street number and street name are needed for all addresses
Landline (e.g. 08 9500 1234 - optional):
Mobile (e.g. 0400 123 456):
Email (optional):
Add me to the email list:
Add me to the email list
Cultural background:
Medical information:
Yes
No
Are there any medical or physical conditions that need to be brought to the attention of the supervisors?
Ambulance cover:
Yes
No
Do you have ambulance cover?
Emergency services permission:
Yes
No
Do you give the City of Cockburn permission to contact emergency services in case of an emergency?
How did you hear about Cockburn Youth Centre? (optional):
Information for parents/guardians
Cancellation procedure
If members are unable to attend their class, the centre must be notified 24 hours prior to the beginning of class. Credits will be given to participants if they notify the centre within this timeframe. If participants do not notify the centre of their absence they are not eligible for a credit. A credit can be used within 3 months (that term/holiday period) of the cancellation date. If the youth centre, for unforseen reasons, cancels a term class the member will automatically be issued with a credit which can be used by liaising with the centres bookings and activities officer for an alternative arrangement.
Behaviour and consequences
Misbehaviour will be dealt with using our warning system. Usually there will be 3 warnings given. On the third warning the young person will be asked to leave the youth centre immediately, and will be given a ban for a specific period of time depending on the severity of the incident and at the discretion of the youth centre staff. The warning level may also be automatically escalated depending on the severity of the breach.
Rules and regulations
For a full explanation of our rules and regulations please see the bill of rights attached (which your child will need to sign). In summary the rules are:
No bullying of any kind
No swearing
No racist or sexist language
No verbal abuse or threats to peers or staff.
No fighting or aggressive behaviour
No weapons or illegal items are to be brought into the centre or any program
No deliberate damage to any property
No stealing
Members are expected to treat staff, equipment and each other with respect at all times. Under no circumstance will anyone that appears the influence of any substance be allowed in the Cockburn Youth Centre.
Duty of care
The City of Cockburn youth centre aims to provide a safe and welcoming environment and our staff will do all they can to make sure all young people are safe and taken care of whilst at the youth centre or participating in our programs. Please note the City of Cockburn staff do not hold the authority to keep young person’s at the centre at the request of parents. The City of Cockburn does not take responsibility for young person’s whom leave the youth centre or who are not on the premises.
Parent / guardian name:
Parent / guardian relationship:
Parent / guardian landline (e.g. 08 9500 1234 - optional):
Parent / guardian mobile (e.g. 0400 123 456):
Parent / guardian email:
I give permission for my child to participate in surveys conducted on behalf of the City of Cockburn, which are for the purpose of evaluating the Youth Services they provide (optional)
Parent / guardian declaration
I agree that in a medical emergency my child will be given appropriate medical assistance and I agree to meet any expenses incurred for medical treatment or transport. My child has read the 'Cockburn Youth services bill of rights' and understands the conditions. I agree that my child may be sent home at the discretion of Cockburn Youth services staff. If my child is sent home due to inappropriate behaviour I agree that refunds will be denied and I will meet any costs incurred. I acknowledge that the City of Cockburn will not be liable for loss, damage or injury to property or person that may occur whilst attending the Cockburn Youth Centre or other Cockburn Youth services programs or activities. I also acknowledge my child will be held accountable for any damages to equipment he/she hires while at the youth centre. This includes hired items that are not returned.
Photo disclosure
Photo permission:
I give permission for photographs or video footage of my child’s participation in any Cockburn Youth Services program to be used by the City of Cockburn for promotional purposes. I agree that I have no claim against the City of Cockburn for any reward for the publication of photographs or videos.
I agree to the terms and conditions outlined above:
I agree to the terms and conditions outlined above
Participant contract
Bill of rights
Everyone attending Cockburn Youth Centre programs and activities has the right to:
Be treated with courtesy, kindness and respect.
Express their feelings and opinions assertively.
Relax and recreate in an atmosphere of harmony and co-operation.
Feel secure and safe in a supportive environment.
Expect that Cockburn YouthCentre rules are fair, consistently implemented and respect the rights of all involved.
Be valued for their individuality including that of race, gender, culture, age, physical or intellectual diversity.
To support these rights we all agree to:
Make all people feel welcome and ask them to join in our activities, or be part of our group.
Treat others with courtesy, kindness and respect.
Listen to other people and try to understand their points of view.
Talk and discuss instead of yelling and arguing.
Help each other and be co-operative.
Watch out for each other to ensure everyone is safe and secure.
Be responsible for our own actions.
Apologise if we hurt someone’s feelings.
Value others for their individual differences.
Respect each other’s property.
Support the Cockburn Youth Centre rules
Cockburn youth services rules
As someone attending cockburn youth centre programs and activities I will
Follow the directions of Cockburn Youth Centre staff.
Respect the youth centre and its property.
Treat all others as I would like to be treated.
I will not
Be mean to people, call them names, put them down, spread rumours about them or do anything else which I know would make them uncomfortable or would upset them.
Use racist or sexist language or insult people on the basis of their religion, sexual orientation, physical or intellectual disability or physical appearance.
Use violent or aggressive behaviour - hitting, punching, kicking, scratching, tripping, spitting, or by any other way.
Threaten to hurt anyone
Bring weapons of any kind into the youth centre and its programs.
Deliberately damage any property including tagging, scratching, spit balls and other forms of vandalism.
Touch or take any property that does not belong to me unless I have permission from the owner.
Bring alcohol or any other illicit substances into the youth centre or on any of its programs.
Be under the influence of any substances. If I am I will be asked to leave and if I refuse the police may be called.
Behaviour and consequences
Misbehaviour will be dealt with using our warning system. Usually there will be 3 warnings given. On the third warning the young person will be asked to leave the youth centre immediately, and will be given a ban for a specific period of time depending on the severity of the incident and at the discretion of the youth centre staff. The warning level may also be automatically escalated depending on the severity of the breach.
Declaration
I have read and understood the Cockburn Youth Centre rules and bill of rights and agree to abide by them. I also understand that if I break any clause in this contract I may be sent home immediately and / or barred from all future cockburn Youth Centre activities and the Cockburn Youth Centre. I also understand that if I break any laws that the police will be notified
I agree to the terms and conditions outlined above:
I agree to the terms and conditions outlined above to submit this form
If you have any questions or queries please contact the Youth Development Officer on (08) 9411 3882 or email
[email protected]
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