Online Form - Youth Services Application

Complete the following online form to apply for membership with the Capel Youth Advisory Collective or Dalyellup Youth Collective.

Once submitted, the Youth Development Officer will be in touch.

Save Your Progress

You have the ability to save this form and complete it at a later date. An email will be generated and sent to the specified address.

Email Address:

Password:

There is no way to resend or recover your password, please write it down.

Note: Incomplete forms are kept for a period of 2 day(s), after this time the system will automatically delete your response.

Participant Details

Name*

Date of Birth*

Locality*

BoyanupCapelDalyellupElginGelorupPeppermint Grove BeachStrathamOther

Please state any medical, allergy, access or dietary requirements*

Youth Service*

Participant Declaration

I WILL NOT participate in any of the following:

- Be mean to anyone including, but not limited to, calling them names, putting them down, spreading rumours, or anything else that would make others uncomfortable or upset.
- Use racist or sexist language or insult people based on their religion, sexual orientation, disability, or physical appearance.
- Use violent, threatening, or aggressive behaviour or language.
- Deliberately damage any property including tagging and other forms of vandalism.
- Touch or take any property that does not belong to me unless I have permission from the owner.
- Bring alcohol or any other illicit substances to any Capel Youth Services programs.
- Be under the influence of any substances. If I am I will be asked to leave and if I refuse the police may be called.

I have read and agree to the above

Declaration*

Yes

Parent / Guardian Details

Name*

Relationship to Participant*

Contact Number*

Email Address*

Emergency Contact - Enter if different from above

Parent / Guardian Declaration

I acknowledge that:

- Instructors are not qualified doctors and can only give first aid.
- I take responsibility for safe participation and well-being, and
- I give permission for my young person to be treated by a medical physician in the event of an emergency.
- The Shire is only responsible for my young person between the start and end of the session and the Shire's duty of care ends at the completion of the session.
- I must remain contactable during the duration of the session.
- I am prepared to collect my young person if they misbehave.
- I will ensure my young person has all requirements for all activities.
- My young person is a willing participant in program activities and will follow all instructions throughout the session.
- If my young person cannot attend one of the sessions, I will let the instructor know with as much notice as possible on 9727 0222.

I have read and agree to the above

Declaration*

Yes

Photo Permissions*

YesNo

Wellness Plan

According to the World Health Organization, Wellness is “the state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity.”

Everyone’s wellness is important to the Capel Youth Services, as the wellbeing and safety of our young people is our number one priority.

By completing this plan, you can provide us with as much or as little detail as you like about what works best for you and what you would like the Capel Youth Services to keep an eye out for.

Contact Person

Things to watch out for and how we can help

Application Statement

In 200 words or less, explain why you would like to apply for this youth leadership program*

Save & Exit