Introduction

Youth Services Program Registration Form

Read before starting

Confidentiality

The City of Port Phillip is committed to protecting the privacy of your personal information.

We use your personal information to:

Provide you/your child with effective case management support
Contact you/your child about our services and programs
Respond to your questions, feedback or complaints
Notify you/your guardian in an emergency
In some instances, de-identified data may be used to support advocacy or service planning and finding acquittals

If there are issues of safety and wellbeing, we are legally and ethically required to report to relevant authority. This includes disclosures of:

Plans to harm yourself or others
If someone else is harming you or plans to harm you

These reports are made in line with our Child Safe Reporting Procedure.

Accessing your personal information

If you want to access or update your personal information, please contact Port Phillip Middle Years and Youth Services via youth@portphillip.vic.gov.au

Please allow up to 10 minutes to complete the form.

You can save and complete later at anytime using the link at the bottom of each page.

Program and young person details

Program information

Which program(s) do you want to attend? *

St Kilda Teen TakeoverEmerald Hill Games ClubSchool Holiday ProgramThrive Pathway Program

Select all you wish to attend

Young person's details

First name *

Last name *

Best phone number to contact young person on *

Street address *

Suburb *

Postcode

What is your connection to Port Phillip? *

LiveWorkStudyRecreate

Date of birth *

Age

Parent/guardian name *This parent/guardian is required to consent to the participation of the young person and sign this form.

Preferred pronouns

She/HerHe/HimThey/ThemPrefer not to say

Do you identify with any specific cultural background or heritage?

What is the primary language spoken at home?

Please tell us the primary language spoken at home

Are you currently attending school/TAFE/University?

YesNo

Current school/TAFE/University

Year levelFor example, "Year 10" or "Second year university"

Do you have any additional support or access needs? *

YesNo

What are your support or access needs? *

Young person's medical information

Does the young person have any medical conditions? *

YesNo

Please provide a brief description of their conditions *

Is the young person taking any medications? *

YesNo

Please note that our staff are not responsible for administering any medication at the program.

Please list the medications *

What are their dietary requirements? *

Does the young person have any allergies, including food, medications, animals? *

YesNo

Please note that snacks will be provided at the program(s) that may contain nuts.

Please tell us the young person's allergy(ies) *

Does the young person require any special care or observation? *

YesNo

Please provide a description of what is required for the young person *

Do we have permission to transport your child if we organise any excursions? *

YesNo

Do you have any medical conditions? *

YesNo

Please provide a brief description of your conditions *

Are you taking any medications? *

YesNo

Please note that our staff are not responsible for administering any medication at the program.

Please list your medications *

What are your dietary requirements? *

Do you have any allergies, including food, medications, animals? *

YesNo

Please note that snacks will be provided at the program(s) that may contain nuts.

Please tell us what your allergies are *

Do you require any special care or observation? *

YesNo

Please provide a description of what is required *

Do we have permission to transport you if we organise any excursions? *

YesNo

How did you hear about the program?

Emergency contact

Young person's emergency contact

First name *

Last name

Relationship to young person *

Best phone number for the emergency contact *

Can you provide an additional emergency contact?

YesNo

First name *

Last name

Relationship to young person *

Best phone number for the emergency contact *

Code of Conduct

This Code of Conduct outlines the expectations and responsibilities for young people participating in programs run by the City of Port Phillip Youth Services. By agreeing to these terms young people acknowledge and agree to the following:

Behaviour expectations of program participation

City of Port Phillip Youth Services is committed to creating a safe, inclusive, and welcoming environment where all young people feel respected, valued, and supported to be themselves.

We expect all participants to:

Show respect and kindness toward staff, peers, and members of the community.
Act in ways that support the safety and wellbeing of everyone.
Follow staff instructions to ensure a positive experience for all.

Discrimination, bullying, harassment, racism, homophobia, transphobia, or any other form of exclusionary or harmful behaviour will not be tolerated. We embrace and celebrate the diversity of all young people, including their identities, backgrounds, and abilities.

If behaviour concerns arise, Youth Services staff will work with the young person to understand what’s going on and explore positive solutions together. Our aim is always to support young people to stay engaged and included in our programs. If behaviour continues to impact the wellbeing or safety of others, a review of the young person’s participation may be required. In extreme cases, it may result in a temporary or permanent ban from our programs.

Participants are expected to take responsibility for their personal belongings. City of Port Phillip is not responsible for lost or damaged property or personal items.

Acknowledgement and agreement

I, {{first name}} {{last name}} agree to the following:

I have read and understood the terms and conditions in the Code of Conduct. *

I consent to participating in the City of Port Phillip Youth Services program under these conditions. *

I understand this agreement may be updated periodically, and I will be notified of any significant changes. *

This Code of Conduct outlines the expectations and responsibilities for young people participating in programs run by the City of Port Phillip Youth Services. By agreeing to these terms, parents/guardians and young people acknowledge and agree to the following:

Behaviour expectations of program participation

City of Port Phillip Youth Services is committed to creating a safe, inclusive, and welcoming environment where all young people feel respected, valued, and supported to be themselves.

We expect all participants to:

Show respect and kindness toward staff, peers, and members of the community.
Act in ways that support the safety and wellbeing of everyone.
Follow staff instructions to ensure a positive experience for all.

Participants are expected to take responsibility for their personal belongings. City of Port Phillip is not responsible for lost or damaged property or personal items.

Acknowledgement and agreement of parent/guardian and young person

{{first name}} {{last name}} and {{parentguardian name}} agree to the following:

We have read and understood the terms and conditions in the Code of Conduct. *

We consent to participating in the City of Port Phillip Youth Services program under these conditions. *

We understand this agreement may be updated periodically, and we will be notified of any significant changes. *

Program consent

I consent to photographs/video footage being taken of me by City of Port Phillip Youth Services and understand that these may be used for promotional materials such as social media, flyers, website and presentations. *

YesNo

I consent to being contacted by City of Port Phillip Youth Services staff by: *Please tick all that apply

Staff are required to comply with the City of Port Phillip’s Code of Conduct when communicating with young people.

I, {{first name}} {{last name}} consent to participating in the City of Port Phillip's Youth Services program(s).

I acknowledge that this is a drop-in program and that I can enter and leave the program at my own desire. City of Port Phillip staff are there to supervise at the program facility.

If I suffer or sustain any injury or illness in the course of or arising out of my participation in the program, I:

Authorise any employee or agent of Port Phillip to administer or cause to be administered such medical measures as he or she may deem necessary or convenient (including the administration of analgesics); and
Shall indemnify and keep indemnified Port Phillip and any of its employees or agents against any cost or expense incurred by Port Phillip arising out of or in any way related to the administration of medical measures referred to in this clause.

I agree to the terms and conditions. *

We consent to photographs/video footage being taken of the named young person by City of Port Phillip Youth Services and understand that these may be used for promotional materials such as social media, flyers, website and presentations. *

YesNo

Both parent/guardian and the young person must agree to consent.

Staff are required to comply with the City of Port Phillip’s Code of Conduct when communicating with young people.

I, {{parentguardian name}}, consent to my child {{first name}} {{last name}} participating in the City of Port Phillip's Youth Services program(s).

I, {{parentguardian name}}, acknowledge that this is a drop in program and not an after school care service, therefore my child can enter and leave the program at their own desire. City of Port Phillip staff are there to supervise whilst my child is at the program facility, however are not responsible for waiting for them to be picked up from the program.

If my child, {{first name}} {{last name}}, suffers or sustains any injury or illness in the course of or arising out of their participation in the program:

I understand that Port Phillip staff will act with care and in good faith. I agree not to hold Port Phillip or its staff responsible for costs arising from emergency medical assistance, unless caused by negligence; and
I give permission for appropriately trained and qualified Port Phillip staff to provide basic first aid and seek medical help if needed. I understand this is to ensure my child’s safety until professional medical care is available.

I agree to the terms and conditions. *

Data privacy and collection

The personal/health information requested on this form is being collected by the City of Port Phillip (CoPP) and will be handled in accordance with the Privacy and Data Protection Act 2014. This information will be used solely by the council for that primary purpose or directly related purposes. The applicant understands that he or she may apply to the council for access to and/or amendment of the information. It will be treated in compliance with the CoPP Information Privacy Policy and the Information Privacy Act.

Yes, I give permission for the City of Port Phillip to store and process my data. *

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