Youth Artist Registration Form

Please fill out this form and a staff member will reach out to confirm your spot.

Please complete one form per child/young person.

This form will ask some demographic questions. This information helps us to better understand your needs and how to support you.

This information also assists us with reporting to the NSW Department of Communities & Justice, who fund this program.

All information provided will be kept strictly confidential.

Which group will your child/young person attend? *

Primary School Group (Wednesdays)High School Group (Tuesdays)

Child's first name *

Child's last name *

Child's date of birth *

Gender *

Address *

Street address *

Suburb/Town/Locality *

Country of birth *

Main language spoken at home *

Is the child of Aboriginal and/or Torres Strait islander origin *

NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait Islander

Dietary Requirements or Allergies

Are there any other special needs or requirements that would be helpful for us to know about?

Parent/Guardian (Given and Family Names) *

Parent/Guardian email address *

Parent/Guardian mobile number *

I give permission for the child listed above to participate in the Queanbeyan-Palerang Regional Council’s Youth Art Group, under the guidance of Council’s Community Development staff. *

I give permission for Queanbeyan-Palerang Regional Council to use photographs/videos including the child/young person under my care in documents produced by and for the Council.

I give permission for my contact details to be added to the Youth Activity Updates mailing list. Queanbeyan-Palerang Regional Council will send updates about school holiday activities, programs, events and other offers for youth in the area.

Parent/Guardian signature *

Draw signature|Type signatureClear

We are using an IT system called the ‘Data Exchange’ to store your child’s information. This system is hosted by the Australian Government Department of Social Services (DSS). You do not have to consent to sharing personal information with DSS. If you do not consent to us sharing personal information, it will not affect the services you receive. If you do consent to sharing 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: https://www.dss.gov.au/privacy-policy.

Do you consent to store personal information in the Data Exchange *

YesNo

Do you consent for future contact for survey/research/ evaluation *

YesNo