School Holiday Workshop Enrolment Form

School Holiday Workshop *

Improv and Intrigue (Wednesday December 18 - Drama Day)
Express Yourself (Friday January 10 - Short Story Writing)
Press Club for Kids (Monday 13 January - Radio)
Press Club for Kids (Tuesday 14 January - Photojournalism)

Child's Name *

Date of Birth *

Address *

Child's Email *

Phone Number *

Parent/Guardian Name *

Parent/Gurdian Address *

Parent/Guardian Phone Number *

Parent Email *

Emergency Contact (if same as parent/guardian state 'as above') *

Expressions Media would like to use images of workshop participants in whole (or in part) for (but not limited to) the company website, newsletters, media releases and promotional materials. The dignity and integrity of individuals will be maintained at all times. If you do not wish for yourself or your child/ren to be photographed or filmed, please indicate here: *

I GIVE MY PERMISSION FOR IMAGES TO BE TAKEN OR USED OF MYSELF OR MY CHILD/REN
I DO NOT GIVE MY PERMISSION FOR IMAGES TO BE TAKEN OR USED OF MYSELF OR MY CHILD/REN

Expressions Media prioritises the health, safety and wellbeing of our participants. Libby Parker is covered for Public Liability insurance with AAMI. Please advise if a participant has a medical condition, any behaviour management or emotional needs, allergies, access needs, or is subject to a court order. This information is kept private and confidential. As a qualified teacher, Libby Parker has a valid police clearance, first aid certificate, mandatory notification certificate and experience working with people of differing needs and abilities. Can you provide details or an action plan for any needs or requirement for your child? *

Yes
No
N/A

Please forward any details or plans to libby@expressionsadelaide.com

Does the participant take any medication that needs to be administered or supervised by staff? *

Yes
No

Does the participant have any allergies? *

Yes
No

Has the participant been diagnosed as at risk of anaphylaxis? *

Yes
No

Does the participant have asthma? *

Yes
No

Does the participant have any other health, wellbeing or access requirements we need to know about? *

Dietary requirements for catered workshops *

ACCESS NEEDS: Does the participant require access support? *

Yes
No

Please indicate first language of workshop participant and any other languages spoken at home. *

Is the workshop participant hearing impaired or visually impaired? *

Yes
No

Does the workshop participant require communication support? *

Yes
No

Does the workshop participant require wheelchair access or have mobility impairment? *

Yes
No

I authorise a representative of Expressions Media to: *

Notify the specified emergency contacts of any accident, injury, illness or trauma involving the participant.
In an emergency, obtain medical assistant for the participant, including ambulance or hospital. I agree to pay all costs incurred.
Administer medical treatment to the participant in the form of action plans provided or minor first aid requirements.

This declaration will be held on file for the duration of the calendar year and will be effective across all Expressions Media programs. If any access requirements change during this period, it is the responsibility of the participant or participant’s parent/caregiver to notify Expressions Media.

Signature/name of Parent/Guardian (if child is under 18 years): *

Date: *

Expressions Media School Holiday Workshop *

One workshop
Two workshops
Three workshops
Four workshops

Total

$ 0.00

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

Captcha *

=

School Holiday Workshop Enrolment Form

One form per child, please.