Online Form - Mayu-Mia - Youth Hub Registration Form

Child Full Name*

Child Age*

Child Gender

Parent or Guardian Contact Name*

Parent or Guardian Contact Number*

Email Address

Name of event/ activity or program your are registering your child:*

Medical Information - Are there any medical conditions or medication requirements we should be aware of? (e.g. food allergies, epilepsy, asthma, diabetes etc.)

Photo Consent - I give consent for images to be taken of my child and for these images to be used, modified, and distributed by the Shire of Carnarvon Youth Services.*

YesNo

Permission Waiver - I hereby release the Shire of Carnarvon, its employees, agents, and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage, or injury (including death) that may be sustained by my child while participating in or traveling to and from any event, activity, program or pick up from Night Patrol.*

YesNo

Child Cultural Background*