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					                               COST: $27.50 (excludes lunch, drinks & munchies)


                           Adventure World - Youth Bus Trip
                                    BOOKING FORM
 Program Information

                                              Please tick:

                                                DAY 1 PROGRAM
                                              Monday 21st December 2009
                                              $27.50 (incl. GST)

                                                 DAY 2 PROGRAM
                                              Tuesday 22nd December 2009
                                              $27.50 (incl. GST)

                                        Suitable for youth ages 11 – 17 years (plus all YAC members).

 Participant Information
   First Name                               Last Name                                         M             F

   Date of Birth                            School                                          Grade
     /   /

                                           How to Make Your Booking Payment:

 Payment Information

Total Cost for the activity is __$____________________ payable to the Serpentine Jarrahdale Shire.

                  Payment Methods:   Cash        Cheque         Money Order          Credit Card
 In Person:                        Via Fax:                              Via e-mail:
 6 Paterson Street                 Attention: Community Development      Attention: Andrew Stuart
 MUNDIJONG WA 6123                 Fax: 9525 5441                        e-mail:
Credit Card Number                                                                             Exp Date

 Cardholder Name                                                   Signature

                                       ABN 98 924 720 841    Serpentine Jarrahdale Shire
                           COST: $27.50 (excludes lunch, drinks & munchies)


                             Parental Release Form

    I hereby give my permission for my child to attend the following “Adventure World” activity:
                               (please tick each activity you will be participating in)

               Monday 21st December 2009                      Tuesday 22nd December 2009
          Pick-up @ the Mundijong Library carpark at 8.15 AM returns to same by 6.00/6.15 PM

•   I realise that it is my responsibility to familiarise myself with the activities on the program, and to ensure
    that my child is dropped off and picked up at the specified departure point at the specified time. Young
    people usually phone or text home to confirm arrival details.

•   I accept that my child must be responsible for their own behaviour and that s/he is a willing participant
    in the activities on the day’s program. I have explained to my child that for safety reasons, they MUST
    stick together with our YAC group on each activity (we recommend in groups of three or four).

•   I give my permission for my child to be treated by a medical physician in the event of an emergency. I am
    aware that the youth leaders & staff will attempt to contact me ASAP, should a medical need arise during
    the course of the activity period.

•   I hereby give my permission for the staff/youth leaders of the activity to contact any emergency services
    where appropriate, or required in an emergency situation.

•   I understand & accept that transportation is provided on both days by our Shire Community Development
    Officer – Youth (Andrew Stuart) on the Shire community & youth bus. I understand it is my responsibility
    to be familiar with the drop-off & pick-up location & times in the information sheet supplied to me.

•   I have read all of the above information and understand it, and have completed the “Emergency
    Treatment Release Form” (over page) to the best of my understanding.

Parent/Guardian Signature:                                                                Date:
Parent’s Full Name:
This bit is for your young person to sign:
• As a participant on the SJ Shire ADVENTURE WORLD 2009 youth bus trip & activities, I agree to abide
  by the “above rules” and I understand and agree that my parents will be contacted, and I may even be
  sent home at my parent’s expense if I break these guidelines & rules.

Young Person’s Signature:
                    Emergency Treatment Release Form

Participant’s Information:
Name:                                                           Age:

Date of Birth:                      Home Phone Number:

Address:                                                  Mobile:

Allergies/Special Dietary requirements:


How much?:

Who gives the medication?:

How often?:

What to watch out for:

Family Doctor:

Doctor’s phone number:

Another Emergency Contact (eg. a relative): (other than home number/s above)
Name:                                               Mobile:

Relationship:                                 Phone#:

Any other information that the activity leaders should know about with regards to your
child participating in the activities?:
Parental Release Form – Photographic Media

ACTIVITY: Adventure World – youth bus trip

Child’s Name:

Parent’s Name:



I hereby give my permission for the Serpentine Jarrahdale Shire and the SJ Youth Advisory
Council to use any photographic images taken of my child/children to be used by the
Serpentine Jarrahdale Shire in any printed publications, youth-focussed newsletter, on the SJ
YAC youth activities website based on the internet or in any other electronic formats for
press, media releases or other suitable purposes.

If any of these images are used, I hereby consent, without further consideration or
compensation to the use (in full or part) any photographic images taken for the purposes of
illustration, broadcast or distribution of any manner.

I understand that all negatives and digital prints remain the property of the Serpentine
Jarrahdale Shire and that there will be no restrictions on the number of times the image may
be used.

I accept that no payment is due in respect of this authority and that no further payments to
me are required at any time.

Upon signing this form I understand that I have no rights to the photos use (as listed above),
however, I do understand that we can receive a copy of the said, photographs by request to
the Serpentine Jarrahdale Shire, through the Community Development Team.

Signed (Parent/Guardian only)..................................................................................................

Date: ...........................................................................................................................................

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