National Youth Week
Open Mic Night Entry Form
youth.gawler.sa.gov.au
Name of Act:
Number of People in Act:
*If performing in a group, each individual must fill out an entry form. All forms should be stapled and submitted together.
Prizes will be awarded for first, second and third place in each category.
Participant’s Information
First Name:
Surname:
Date of Birth:
Age:
Sex:
 Male
 Female
Address:
Home phone:
Mobile:
Email**:
**Performers must have an active email address that they check regularly. Schedules and additional information on the
National Youth Week Open Mic Night will be sent via email to performers.
Check the one that applies to you
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Poet/Writer
Musical Act
(Solo)
Musical Act
(Duet or Band)
Dancer
Comedian
Other
Description of Act (Please note that pyrotechnics, animals,
vehicles powered or otherwise are not permitted)
Duration of Act (you may perform up to 10 minutes)
Sound requirements (Check the one that apply)


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Single Vocal Mic
iPod or CD
Playback (Solo)
Acoustic Guitar
(Mic)
Electric Guitar
(Amp)
Other Direct
Instruments
Other Mic’d
Instruments
List any equipment you require for your Act
(chairs, table etc.)
Emergency contact information
Contact Person
Contact 1:
Contact 2:
Relationship
Home Phone
Work Phone
National Youth Week
Open Mic Night Entry Form
youth.gawler.sa.gov.au
Conditions of Entry and Consent
The following conditions must be noted and adhered to:
1.
2.
3.
Persons entering and participating in the National Youth Week Open Mic Night do so at their own risk.
The Town of Gawler accepts no liability for loss, damage and injury whatsoever which may be brought, made or claimed against it in relation to participation in the National Youth Week Open Mic Night event.
Persons aged 12 to 25 years are eligible to participate in the National Youth Week Open Mic Night event.
As the participant or parent/ guardian of _____________________________ I, ______________________________ give
consent for him/her to take part in the National Youth Week Open Mic Night event to be held at the Youth Shak, Gawler Sport
and Community Centre on Saturday 1 April 2017.
I understand that supervision for the event will be provided by Town of Gawler staff members. All event activities will be
delivered by Council staff, volunteers or facilitators that have appropriate clearances and training.
The staff and supervisors have my authority to take whatever action they think necessary to ensure the safety, well-being and
appropriate conduct of the participants as a group or individually in the above mentioned activity.
If I / my child becomes ill or is injured, staff may obtain on my behalf whatever medical treatment I / my child requires at my
expense.
I consent to audio and visual footage, photographic images and documents of myself / my child being developed and used by
the Town of Gawler for promotional, educational and artistic purposes. Audio/ visual footage, images and/or documentation
may be used for Town of Gawler website and Facebook pages, other social media, print media, radio, television and promotional
material. I understand that all material remains the sole property of the Town of Gawler.
 Yes  No
By signing this waiver, I disclaim any person or company of any liabilities whatsoever.
First Name:
Surname:
Signature:
Date:
Parent/ Guardian (if under 18 years)
First Name:
Surname:
Signature:
Date: