Glossop Skills Hub Enrolment Form – Term 2
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Negotiated
Referring Agency/School
27th April – 29th Jun 2015 $350 Course
$100 Materials
29 April – 1st Jul 2015
$350 course
$50 Materials
5 week program
$280
Choose an item.
Other:
Agency/School Contact person
Email
Phone No.:
Billing Details
Where is the invoice sent?
Mobile Phone No.:
Personal Details
Participant/Student Name:
School Attending
Home Phone No.:
Mobile Phone No.:
Date of Birth:
Gender:
Details of Person to be Notified in the event of an Emergency
Name:
Home Telephone No.:
Mobile Telephone No.:
Work Telephone No.:
Relationship:
Special requirements
Personal - any information that will
assist the trainer to work with the
student re physical or personal
limitations
Risks – court orders, restrictions or any
potential risk
☐ Allergies
Medical Conditions
☐ Asthma
☐ Seizures
☐ Heart
condition
☐ other:
Comments
Referral worker signature
Date
Page 1 of 4
Formal agreement – Parent/Guardian
1.
In the case of an emergency , I understand that any cost incurred will be my responsibility and I
give permission for _______________________
i. To be taken to the nearest doctor or hospital by ambulance or car and contact made with
the parent(s)/caregiver(s) as soon as possible.
ii. To obtain medical attention.
Yes / No
2.
Excursions are often scheduled to support the educational programs, I agree that my child can
take part in such excursions.
Yes / No
3.
I agree that my child can travel in FWS vehicles where appropriate.
4.
I agree that if my child, as a passenger in a car/van, is behaving in such a manner as to make
conditions unsafe he/she will be removed from the program and will become the responsibility of
the case manager or referring organisation. I understand that I or my emergency contact will be
notified of the situation immediately.
Yes / No
5.
I agree that if my child is behaving in such a manner that is disruptive and/or dangerous to others,
she/he will be removed from the program and will become the responsibility of the case manager.
I understand that I or my emergency contact will be notified of the situation immediately.
Yes / No
6.
I agree that my child may watch videos deemed suitable by the teaching staff.
7.
I agree that my child may be photographed engaged in daily activities at Glossop Skills Hub and
displayed at the centre and in newsletters/publications.
Yes / No
8.
I agree to the expectations around the appropriate use of mobile phones and other electronic
devices
Yes/ No
Yes / No
Yes / No
I have read the above agreements and give my consent to all information stated in this Enrolment
Form.
Parent/Guardian Name
Parent/Guardian Signature
Date
Page 2 of 4
Protection of Privacy & Consent to Release Information
I,
agree that for FWS to provide ongoing
support, services and training to me they can have access to personal information while I am engaged
in a program. Specifically to:
9. OBTAIN INFORMATION
I give permission for FWS to receive information from the following:
Agency or Worker
Initial
10. RELEASE INFORMATION
I also give permission to FWS to release information to medical services in the situation of an
emergency. Please be advised that in the event of an emergency FWS reserves the right to call an
ambulance to attend.
The contents of this authorisation have been explained to me and I understand the nature of the
information.
Guardian/Advocate signature
Student/participant signature
Printed Name
Date
All persons have the right to confidentiality. Information revealed will remain with the professional
setting. There are however legal exceptions to this. Information must be divulged when:
 Ordered by the court
 Or police
If you have concerns about the way in which your personal information is being managed you should
discuss these concerns with your provider, the department or agency concerned or with the Federal
Privacy Commissioner, who can be contacted at www.privacy.gov.au.
Information received will be treated in accordance with the FWS Privacy Policy and procedure which
can be accessed from the Website www.fws.org.au
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