Youth school holiday program April 2026

Dear Parent/Guardian

Your child’s participation in the youth school holiday program is conditional upon the submission of this form. Note that the information that you give will not prejudice your child’s participation. We need to know the following information as it will help us better carry out our responsibility of care. Thank you for your cooperation.

COVID-19 information

Remember your child must not attend on the day if:

they have have tested positive for COVID-19
they’re unwell, have experienced cold or flu symptoms, fever or recent loss of smell or taste
they have had close contact with a confirmed case of COVID-19 in the last seven days

Activity details

I give permission for child (named below) to attend an excursion conducted by the Southern Midlands Council selected below. Only one activity will be allocated per child to enable new families to participate. If the activity is full, a waiting list will operate and parents will be contacted if a place becomes available.

For which activity do you wish to register your child? *

Thursday 23rd April 2026 – Rockit Climbing and Hobart Aquatic Centre – Grades 6 to 11Thursday 30th April 2026 - Tool Skool with Asher followed by BBQ and Swim at the Oatlands Aquatic Centre - Grades Prep to 5

Pick-up location *

Bagdad Community ClubKempton opposite St Mary’s ChurchOatlands Roche Hall car park (Campbell Street)

Participant’s personal details

Participant’s first name *

Participant’s last name *

Participant’s grade at school *

Participant’s date of birth *

Participant’s mobile phone number

Participant’s gender *

MaleFemaleOther

Participant’s street address *

Address *

City *

State *

Postcode *

Participant’s country of birth *

Main language spoken at home *

Participant’s ethnicity *

Does the participant identify as Aboriginal or Torres Strait Islander? *

YesNoPrefer not to say

Participant’s disability status *

Mother/guardian personal details

Mother/guardian first name *

Mother/guardian last name *

Mother/guardian email address *

Mother/guardian phone *

Father/guardian personal details

Father/guardian first name *

Father/guardian last name *

Father/guardian email address *

Father/guardian phone *

Emergency contact 1

Please provide contact details in case of an emergency or accident.

Emergency contact 1 first name *

Emergency contact 1 last name *

Emergency contact 1 phone *

Emergency contact 1 street address *

Address *

City *

State *

Postcode *

Emergency contact 2

Emergency contact 2 first name *

Emergency contact 2 last name *

Emergency contact 2 phone *

Emergency contact 2 street address *

Address *

City *

State *

Postcode *

Medical information

Family doctor’s name *

Family doctor’s phone *

Family doctor’s street address *

Street address *

City *

State *

Postcode *

Medicare number *

Private health fund name

Private health fund number *

Is your child regularly taking any tablets or other medication?

YesNo

Please list any tablets or other medication your child is regularly taking. *

Has your child been taken off medication recently? *

YesNo

Please give details of any medication your child has been taken off recently. *

Do you give permission for your child to be given paracetamol (e.g. Panadol) as pain relief if required? *

YesNo

What is the year of your child’s last tetanus injection? *

Can your child swim? *

NoFair swimmerGood swimmer

Please provide details of any recent illness, health concerns, medical conditions, allergies, any medications your child takes regularly, and any other matters staff need to be aware of e.g. asthma, epilepsy, diabetes, allergies. *

Photography

I consent to my child’s photograph being taken and/or displayed in Council publications or reporting purposes.

Parent/guardian agreement

I acknowledge that Council will make every endeavour to ensure the safety and wellbeing of my child but will not be held responsible for any accident, injury or illness that may arise during the above excursion. *

I agree that in the event of injury to my child, Southern Midlands Council’s Youth Program's employees agents and voluntary helpers are authorised by me to obtain at my expense any medical, ambulance or like services which Southern Midlands Council’s Youth Program in your absolute discretion think necessary or desirable. *

In allowing my child to participate in the program, I consent to their participation in a range of sporting and recreational activities. I also consent to my child being able to participate in “PG” rated movies in the absence that “G” rated is not available. *

I acknowledge that the information provided on this form is true and accurate. *

Children are expected to be respectful, kind, and cooperative with staff and peers.

Follow instructions during activities for safety and smooth operation.

Full name of parent/guardian submitting this form *

Email address of parent/guardian submitting this form *

Phone number of parent/guardian submitting this form *

Privacy

Personal information collected by Council is used for the purposes in which it is collected. Personal information is held securely and used solely by Council for a specific and/or directly related purposes. Council may disclose this information to other organisations if required or as permitted by legislation.

Anyone providing information understands that their personal information is provided for the specific purpose and that they may apply to Council for access to and/or amendment of the information.

View the Southern Midlands Council privacy policy.

Date *

Return to the Southern Midlands Council website.