Youth and Community Participant Registration Form

Are you a parent or a young person? *

ParentYoung Person (under 24 years old)

How many young people are you registering? *

123

Please answer the questions below for each young person.

Which program are you attending? *

First Name *

Last Name *

Date of Birth *

Phone Number *

Gender

Preferred Pronouns

Do you identify as Aboriginal or Torres Strait Islander? *

AboriginalTorres Strait IslanderWould rather not sayNone of the above

Country of Birth *

Main language spoken at home *

Do you have any allergies or medical conditions?

Please Specify

Do you have any additional needs that we should be aware of?

Please Specify

Please tick if you are 16 years of age of over

First Name (Young Person 2) *

Last Name (Young Person 2) *

Date of Birth (Young Person 2) *

Phone Number (Young Person 2) *

Gender (Young Person 2)

Preferred Pronouns (Young Person 2)

Do you identify as Aboriginal or Torres Strait Islander? (Young Person 2) *

AboriginalTorres Strait IslanderWould rather not sayNone of the above

Country of Birth (Young Person 2) *

Main language spoken at home (Young Person 2) *

Do you have any allergies or medical conditions? (Young Person 2) *

Do you have any additional needs that we should be aware of? (Young Person 2) *

Please tick if you are 16 years of age of over (Young Person 2)

First Name (Young Person 3) *

Last Name (Young Person 3) *

Date of Birth (Young Person 3) *

Phone Number (Young Person 3) *

Gender (Young Person 3)

Preferred Pronouns (Young Person 3)

Do you identify as Aboriginal or Torres Strait Islander? (Young Person 3) *

AboriginalTorres Strait IslanderWould rather not sayNone of the above

Country of Birth (Young Person 3) *

Main language spoken at home (Young Person 3) *

Do you have any allergies or medical conditions? (Young Person 3) *

Do you have any additional needs that we should be aware of? (Young Person 3) *

Please tick if you are 16 years of age of over (Young Person 3)

Address *

Street address *

City *

State *

Postcode *

Email Address *

Would you like to join our mailing list? *

Emergency Contact Name *

Relationship *

Emergency Contact Phone Number *

Do you consent for Hills Community Aid to take and use photographs for promotional purposes? *

YesNo

How did you hear about Hills Community Aid?

Do you have permission to make your own way home? *

YesNo

Do you consent for us to collect this information for reporting purposes to the Department of Social Services Data Exchange (DS)?

The information you provide on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. We are using an IT system called the ‘Data Exchange’ to store your information. This system is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us for the purpose of managing your case.

You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do consent to sharing your personal information with DSS, you can ask for this information to be removed at any time. DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g. your name).

DSS combine your data with other clients’ data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grants programs, and conduct research and evaluations. DSS may use this data to produce reports. These reports may be shared with other organisations. The data in these reports is de-identified.

You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website.

*

Do you consent to future contact from the Department of Social Services Data Exchnange (DS) for survey/research/evaluations? *

YesNo

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