SECC Youth Program Registration Form
Programs start at the beginning of Term 4
Location: Shop 84, Eastlakes Shopping Centre, Eastlakes 2018
Contact number (02) 8338 8506
Name *
Your answer
Age *
Your answer
Email *
Your answer
Phone number *
Your answer
Your answer
Cultural Identity
How did you hear about us?
If referred, who by?
Your answer
What school do you attend?
Your answer
What year are you in at school?
Any known medical issues?
Your answer
Would you like to receive notices of South Eastern Youth Connect's activities or events?
If yes, what method of contact would you prefer?
What activities would you like to attend *
Summer Holiday Activities
Caregiver's Full Name
Your answer
Caregiver's Phone Number
Your answer
Do you grant permission to South Eastern Community Connect to take photographs or video recordings of yourself and your voice and use photographs or video recordings they take whilst participating in South Eastern Community Connect's Youth Program. Furthermore, do you grant South Eastern Community Connect the right to reproduce, use, exhibit, display, broadcast and distribute and create derivative works of these images and recordings in any media now known or later developed.
South Eastern Community Connect has a strict policy around issues of privacy and confidentiality. All files are securely maintained. Your name and personal details will not be given to any person or agency outside of the organisation without your informed and voluntary consent. Exceptions to this agreement involve:• Where a child or young person under the age of 16 years is at risk of significant harm from abuse or neglect (e.g. a child or young person witnessing incidents of Domestic Violence)• Where there is a serious and imminent threat to life and health of any person, including the person seeking a service (e.g. a person is at risk of hurting themselves or harming others)• Where a person discloses information that would substantially assist in the prosecution of any offence punishable by 5 or more years imprisonment• Where a worker is required to provide documents (e.g. a person’s file) or give evidence under subpoena. Your worker can describe these exceptions in more detail. If you have any questions please make sure you ask your worker. Do you understand?
SECC collects basic program statistics. The collection is for funding and reporting purposes. The collection never identifies individuals. The collection allows us to monitor service usage patterns across the years. It also allows us to report to our Board of Directors and the bodies that provide us with funding for service provision. At no stage is any identifying data provided to either the Board of Directors or to funding bodies. If you choose to not have this particular information passed on you are able to inform the worker. You will still be able to receive services from SECC. Do you consent to the collection of statistics for the purposes stated above on the condition that any collection will not identify you personally?
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