REGISTRATION FORM
KEY PROGRAM DATES

2nd & 3rd May 2015- Training Weekend: Non-residential program to be held in central Adelaide 5th -10th July 2015- Parliament Week: Full residential program April- June: Team meetings as required
CONDITIONS & COMMITMENTS OF ENTRY     Respect the apolitical status of the program and refrain from activities which would jeopardize this status Compulsory attendance of Training Weekend based in Adelaide city Compulsory attendance of Parliament Week (6 day residential camp) based in the Adelaide suburbs Attendance at and participation in team meetings (minimum 4 from April-July) and a commitment to sharing in the workload of your team in the process of researching and writing your Bill  Carry out all instructions given by the Youth Parliament Taskforce and YMCA staff  Treat all involved in Youth Parliament with respect  Provision of your own transport to and from these events (although transport provided during Parliament Week) Payments:  A deposit of $50 is required upon application  The rest of the program fee must be paid BEFORE Training Weekend  The program fee is non-refundable (unless exceptional circumstances, where-by prompt written notice is required) PERSONAL DETAILS
We aim to have the South Australian community represented at Youth Parliament. Below are a number of personal questions, please fill in as many as you are comfortable to answer and this will help us to develop a participant profile.

1. Full Name: ________________________________ 2. If you are applying as a part of an already formed team, please indicate team name:_______________ 3. Address: _________________________________ ____________________________P/C: __________ 4. Home Phone: ____________________________ Mobile:___________________________________ 5. Email: ____________________________________ 6. Age: _____________ DOB: ____/___/__________ 7.  Male  Female

8.  Aboriginal/Torres Strait Islander 9.  Culturally Diverse. Country of Birth______________ Please indicate if you are  Refugee  Newly arrived 10. Do you identify as having a disability/special need?
Mental Health issues Autism/Asperger’s Physical Intellectual  Brain Injury Other ________________

11. Are you/were you under Guardianship of the Minister?  Yes  No 12. Do you have caring responsibilities at home?  Yes  No 13. Do you identify as being LGBTIQ?  Yes  No

Return to E michelle.brown@ymca.org.au | F (08) 8353 0384 | P YMCA Youth Parliament PO Box 20 Fulham Gardens SA 5024

OCCUPATION & EXPERIENCE 14. Are you a past Participant: Yes / No If yes, tell us what year(s): ________________________________________ 15. School/Uni/TAFE/Workplace Name: ____________________________________ Suburb___________________

16. A SACE pack can be obtained from the YMCA’s website for information on how we deliver the SACE component of Youth Parliament. Please tick if you are interested in SACE accreditation as part of your participation in the program?  Stage 1 Do you have a teacher at your school willing to support you? Please provide their details: Name: ___________________________________ Role:_______________________________________ E:_____________________________________________________PH:___________________________

17. In what ways are you currently involved in your community? Please tick and describe relevant areas. Sport/Recreation _________________________ Service Club _____________________________ Religious/Cultural Group _________________ Political/Activist Group______________________________ Committee/Advisory Group __________________________ Other ________________________________

________________________________________________________________________________________ 18. On a scale of 1-5, 1 being poor, 5 being excellent (please circle), how would you rate your general knowledge of: Local Government 1 - 2 - 3 - 4 - 5 State Government 1 - 2 - 3 - 4 - 5 Federal Government 1 - 2 - 3 - 4 - 5

19. How did you find out about the Youth Parliament program? Youth Parliament Website Past Participant Friend Local Council Youth Organisation School/TAFE/Uni Other_____________________________

20. Are there any particular issues in your community/this state that are important to you? _______________________________________________________________________________________________ _______________________________________________________________________________________________ 21. What do you hope to get out of Youth Parliament?
______________________________________________________________________________________________ ______________________________________________________________________________________________

22. Are you willing to receive information on any other YMCA programs in the future?

YES

NO

HEALTH INFORMATION 23. Emergency Contact 1 Name & Relationship: Contact numbers: 24. Emergency Contact 2 Name & Relationship: Contact numbers: 25. Doctor’s Name and Number: 26. Medicare Number: 27. Do you have Private Health Insurance? Company: Member Number: 28. Do you have Ambulance Cover? 29. Have you been immunized against Tetanus? Approximate date/year: 30. Has your appendix been removed? 31. Any special dietary requirements:
(eg. Vegetarian, Vegan, Halal, Diabetic etc)



Yes

 No



Yes



No

32. Any other special needs:

33. Do any of the following conditions/allergies affect you? Yes No Asthma: Epilepsy: Diabetes: Sleep Walking: Hearing Loss: Heart Problems: Bed Wetting: Hay Fever: - - - - - - - - Details ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ Allergy to insect bites: Allergy to food: Yes No - - Allergy to other (i.e. drugs):  -  Strenuous exercise: - Medical allergies: - Diet restrictions: - Behavioural problems:  -  Emotional problems: - Details _______________ _________________ _________________ _________________ _______________ _ _________________ _________________ _________________

34. Do you use an EpiPen?  Yes  No

35. Do you have any other medical issues, or have you been under a Doctor’s care recently?  Yes  No
If yes, please describe (attach further details if appropriate): _____________________________________

____________________________________________________________________________________________________________________

36. Are you taking any medication? If so, please specify:

_____ __________________

___

PARTICIPANT CONSENT AND DECLARATION
1.

2.

3. 4. 5. 6. 7. 8. 9.

I wish to participate in YMCA Youth Parliament 2015. The information I have provided is true and accurate. I have carefully read the conditions and commitments of entry and am prepared to meet these if accepted into the program. I hereby agree that the YMCA and its officers, leaders and staff shall be, to the full extent permitted by law, released from and shall not incur any responsibility or liability whatsoever for any accident or injury sustained by myself in the activities included on this application or for any damage to or loss of my personal property. I understand the YMCA of SA does not accept any responsibility for any personal items that I may choose to bring to the sessions. I acknowledge that if I am required to take medication or eat regularly or have any other special needs it is my responsibility to look after my own health. I understand that I will be required to attend all sessions of the Program, unless I am unable to do so due to cultural, mobility or health reasons, and have sought permission direct from the Program Manager. I further authorise you to obtain, at my cost medical/ambulance assistance in the case of accident or emergency that may involve me. I hereby give permission to participate in the key events of Youth Parliament and all aspects of the program including the local team meetings facilitated by mentors and various recreation activities during the events. I hereby give permission to travel by YMCA bus/car during the program. I hereby give permission for any photographs and video recording taken by staff from the YMCA of South Australia to be used for promotional purposes (i.e. for use on social media, slideshows, posters or our website): Yes  No 
DATE: ______/ /____ __

SIGNED: Parent Declaration (for under 18’s):

I authorise the Project Manager supervising the Youth Parliament or their delegate to consent, where it is impractical to communicate with me, to the participant receiving such medical or surgical treatment as may be deemed necessary by medical professionals, and agree to meet any expense attached thereto including transport by SA Ambulance Service. I agree that my child may receive First Aid treatment as necessary. I hereby give my permission for my child to participate in all aspects of the program and validate the above consents and declarations. SIGNED: (Parent or guardian) DATE: ___ ________________ / / ____ _____

PRIVACY
The YMCA of South Australia acknowledges and respects the privacy of individuals. The information provided within this documentation is used solely for the purposes listed: 1) Processing your enrolment with the YMCA of South Australia 2) Providing you with updated information 3) Assisting us improve our services to you By completing this application form, the YMCA of South Australia accepts that the care recipient/carer of the named participant have consented for this information to be collected. The intended recipients of this information are the YMCA of South Australia, its authorised staff and relevant Government authorities. You have the right to access and alter personal information relating to yourself in accordance with the Commonwealth Privacy Act and YMCA of South Australia Privacy Policy.

Thank you for your application to YMCA Youth Parliament 2015. We will notify you as soon as possible to let you know if you have been accepted.